A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

Choice A rationale:

The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.

Choice B rationale:

The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.

Choice C rationale:

This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.

Choice D rationale:

The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.

Choice A rationale:
Preterm gestational age is not indicated by the presence of breast tissue with a flat areola and no bud. Preterm newborns may have immature breast tissue, but it does not manifest as a flat areola with no bud.

Choice B rationale:
Decreased maternal hormones during pregnancy would result in less developed breast tissue in the newborn, but it wouldn't present as a flat areola with no bud. Instead, the breast tissue may be small and less pronounced.

Choice C rationale:
Congenital anomaly refers to a birth defect or malformation that occurs during fetal development. In this case, the flat areola with no bud suggests an abnormality in the development of the breast tissue. Further assessment and evaluation may be required to determine the exact nature of the anomaly.

Choice D rationale:
Ambiguous secondary sex characteristics would involve the presence of characteristics that are not clearly male or female. The described breast tissue does not fit this category, as it is specifically described as having a flat areola with no bud, which is more indicative of a congenital anomaly.
Question 65.