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 A
Explanation
Choice A reason: The client is Rh negative and the newborn is Rh positive is correct, as this finding indicates a risk of Rh incompatibility and sensitization. Rh incompatibility occurs when the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause maternal antibodies to atack the fetal red blood cells. Sensitization occurs when the maternal antibodies cross the placenta and enter the fetal circulation, which can cause hemolytic disease of the newborn. The nurse should administer Rho(D) immune globulin to prevent sensitization and protect future pregnancies.
Choice B reason: The client is Rh negative and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice C reason: The client is Rh positive and the newborn is Rh positive is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-positive blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice D reason: The client is Rh positive and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If the mother has Rh-positive blood and the baby has Rh- negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Correct Answer is D
Explanation
Choice D reason:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take, as it can relieve pressure on the cord and prevent compression and fetal hypoxia. The nurse should also use a sterile gloved hand to hold the presenting part off the cord.
Choice A reason:
Preparing the client for an emergency cesarean birth is an important action, as it can facilitate prompt delivery and prevent fetal compromise. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
Choice B reason:
Covering the cord with a sterile, moist saline dressing is an important action, as it can prevent drying and infection of the cord. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord compression.
Choice C reason:
Explaining to the client what is happening is an important action, as it can provide emotional support and education for the client. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
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