A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?
Wear a nipple shield.
Express milk from both breasts.
Obtain a prescription for an antibiotic.
Apply a heating pad to her breasts.
The Correct Answer is B
Choice A reason: Wear a nipple shield is incorrect, as this recommendation is not indicated for a client who has engorged breasts. A nipple shield is a thin, flexible device that covers the nipple and areola and can help with latch problems, flat or inverted nipples, or sore nipples. However, a nipple shield can also reduce milk transfer, stimulate less milk production, and cause nipple confusion or preference.
Choice B reason: Express milk from both breasts is correct, as this recommendation can help relieve engorgement and maintain milk production. Engorgement is a normal and expected phenomenon that occurs when the milk comes in, usually around 72 to 96 hr after birth. Engorgement can cause breast fullness, tenderness, warmth, and hardness. The nurse should advise the client to express milk from both breasts by breastfeeding frequently and effectively or by using a breast pump or hand expression.
Choice C reason: Obtain a prescription for an antibiotic is incorrect, as this recommendation is not indicated for a client who has engorged breasts. An antibiotic is used to treat mastitis, which is an infection and inflammation of the breast tissue that can cause redness, pain, swelling, warmth, and fever in the affected breast. The nurse should assess the client for signs of mastitis and report any abnormal findings to the provider.
Choice D reason: Apply a heating pad to her breasts is incorrect, as this recommendation can worsen engorgement and cause discomfort. A heating pad can increase blood flow and swelling in the breasts, which can impair milk flow and increase pain. The nurse should advise the client to apply cold compresses or cabbage leaves to her breasts to reduce inflammation and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.
Choice B reason: Sit on an inflatable donut to protect the perineum is incorrect, as this can increase pressure and blood flow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.
Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.
Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.
Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.
Correct Answer is A
Explanation
Choice A reason: In 3 to 5 days after delivery is correct, as this is the average time for breast milk production to begin after birth. Breast milk production is stimulated by the drop in progesterone levels that occurs after the placenta is delivered, as well as by the suckling of the baby. The nurse should encourage the client to breastfeed frequently and effectively to promote milk production and prevent engorgement.
Choice B reason: In 6 to 8 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
Choice C reason: Within 2 days after delivery is incorrect, as this is a shorter than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should educate the client that before breast milk comes in, the breasts produce colostrum, which is a thick, yellowish fluid that contains antibodies and nutrients for the baby.
Choice D reason: In about 10 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
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