A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked.Which of the following statements should the nurse make?

The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:

1. Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
2. Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.

So, the completed sentence would be:

• The nurse should first monitor the client's fundal tone followed by the client's blood pressure.

Taking care of immediate risks and stabilizing the patient is key in such cases.

Choice A rationale

Delay in initiating breastfeeding can occur after a cesarean birth due to the effects of anesthesia, postoperative recovery, and the need for medical monitoring, which can delay the mother’s ability to start breastfeeding.

Choice B rationale

Routine use of intubation equipment is not standard practice during a cesarean birth. Intubation is typically reserved for patients who require general anesthesia or have complications that necessitate airway management.

Choice C rationale

The need for an indwelling urinary catheter is common during a cesarean birth. It helps to keep the bladder empty and out of the way during the procedure and is usually placed after anesthesia and removed shortly after the surgery.

Choice D rationale

Management of postpartum pain is an important topic to discuss with clients undergoing cesarean birth. Postoperative pain management may include medications and non-pharmacological methods to ensure comfort and aid in recovery.