A woman gave birth 48 hours ago to a healthy infant girl.
She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.
Which guidance should the nurse provide to the client at this time?

Choice A rationale

Puerperal infection, an infection of the reproductive tract after childbirth, is a risk factor for all postpartum women. However, a large newborn size (macrosomia) increases the risk of prolonged labor, increased instrumentation during delivery, and postpartum hemorrhage, which indirectly increases the risk of infection but is not the most direct immediate risk related to the newborn's weight.

Choice B rationale

Retained placental fragments are a risk factor when the placenta does not deliver intact. While a large newborn can sometimes be associated with difficulties during placental delivery, it is not the primary direct risk factor immediately following birth. Uterine atony is a more immediate and direct risk related to uterine overdistension.

Choice C rationale

Thrombophlebitis, the formation of blood clots in the veins, is a postpartum risk factor related to hormonal changes, immobility, and hypercoagulability. While factors like prolonged labor (more common with large babies) can contribute, it is not the most immediate and direct risk in the first few hours postpartum for a woman who delivered a large newborn.

Choice D rationale

A newborn weighing 9 lb 6 oz (4252 g) is considered macrosomic. This large size can lead to overdistension of the uterus during pregnancy and labor. Uterine overdistension impairs the ability of the uterine muscles to contract effectively after delivery, a condition known as uterine atony. Uterine atony is the primary and most immediate risk for postpartum hemorrhage in women who have delivered large newborns. .

Choice A rationale

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B rationale

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C rationale

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D rationale

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.