A nurse is caring for a client with the nursing diagnosis of acute pain related to breast engorgement.
Which interventions should the nurse include in the plan of care?

Choice A rationale

Symmetrical breast swelling with a sudden increase in milk production is characteristic of normal postpartum breast engorgement as lactation is established, not mastitis. Mastitis is usually localized to one breast.

Choice B rationale

Swelling and redness in one breast, accompanied by flu-like symptoms such as fever, chills, and body aches, are classic signs and symptoms of mastitis, an infection or inflammation of the breast tissue.

Choice C rationale

Bilateral breast tenderness and engorgement without fever are typical findings of normal postpartum breast engorgement, which occurs due to increased blood flow and milk production. Fever is a key indicator of infection, such as mastitis.

Choice D rationale

A white patch on a nipple is more indicative of thrush (candidiasis), a fungal infection that can occur during breastfeeding, affecting the nipple and the baby's mouth. While uncomfortable, it is distinct from mastitis.

Choice A rationale

While support from family is beneficial, advising the client to solely rely on family for stress reduction and baby care without further assessment may delay the identification and treatment of a potential postpartum mood disorder. It's crucial to first understand the underlying cause of her feelings.

Choice B rationale

Encouraging rest is a general recommendation for postpartum recovery and fatigue. However, the client's report of anxiety, irritability, and feelings of inadequacy suggests more than just typical postpartum fatigue and warrants a more focused assessment for a mood disorder.

Choice C rationale

The client's symptoms of anxiety, irritability, inability to sleep despite fatigue, and feelings of inadequacy are indicative of a potential postpartum mood disorder, such as postpartum depression or anxiety. A thorough assessment using standardized screening tools and further questioning about the onset, duration, and severity of these symptoms is the most appropriate initial action to determine the need for further intervention and support.

Choice D rationale

While some emotional fluctuations are common in the immediate postpartum period ("baby blues"), the combination and intensity of the client's reported symptoms, particularly the feelings of inadequacy and persistent sleep disturbance despite fatigue, suggest a need for further evaluation rather than simply reassurance that these feelings are normal and transient. .