During a home visit, the nurse learns that a new mother is experiencing breast engorgement.
What would the nurse recommend to help alleviate this problem?

Choice A rationale

Postpartum hemorrhage (PPH) is a significant risk for this client due to several factors including a macrosomic neonate (birth weight >4000 grams), which causes overdistention of the uterus. Uterine overdistention stretches the muscle fibers, impairing the uterus's ability to contract effectively (uterine atony) after birth, which is the leading cause of PPH (normal blood loss range: ≤ 500 mL for vaginal birth).

Choice B rationale

A rapid labor (4 hours) and the birth of a macrosomic neonate (4200 grams) increase the risk of vaginal lacerations and tears to the soft tissues of the birth canal. The rapid passage of a large fetal head/shoulder diameter can cause uncontrolled and forceful tearing, often extending into the perineal musculature, leading to potential complications and excessive blood loss.

Choice C rationale

Uterine inversion, the collapse of the fundus into the endometrial cavity, is a rare but severe complication. While associated with factors like aggressive cord traction or fundal pressure, this client's history of macrosomia and rapid labor primarily increases the risk for uterine atony and lacerations, making inversion a much less likely, though possible, complication.

Choice D rationale

Postpartum hypertension (PHTN) is generally related to a history of pre-eclampsia or chronic hypertension. This client's presentation of macrosomia and rapid labor primarily increases the risk for mechanical/anatomical complications like uterine atony and lacerations rather than a primary vasospastic or systemic vascular disorder such as PHTN.

Choice A rationale

Placing a rolled towel under the client's knees causes increased pressure on the popliteal space, potentially compressing the popliteal vein, which increases the risk of deep vein thrombosis (DVT) in the client. This is particularly concerning during labor due to physiologic hypercoagulability and potential for immobility. The priority action must focus on fetal and maternal well-being following rupture of membranes (ROM). This action is non-essential and potentially harmful.

Choice B rationale

While notifying the healthcare provider is crucial, it is not the immediate priority when there is a risk of a severe complication like umbilical cord prolapse following the spontaneous rupture of membranes (ROM). The nurse's immediate action must be to rule out or intervene for fetal distress or cord prolapse. The provider can be notified after the initial fetal status assessment is complete, especially the fetal heart rate (FHR).

Choice C rationale

Administering oxygen via a non-rebreather mask (NRB) is indicated for maternal or fetal hypoxemia or distress, or as part of resuscitation measures. In an initially stable client without signs of severe respiratory distress or non-reassuring fetal heart rate (FHR) patterns, oxygen administration is not the priority. The initial action must be a rapid assessment of fetal status, specifically ruling out cord prolapse after rupture of membranes (ROM).

Choice D rationale

Rupture of membranes (ROM) prior to the fetal head being engaged or firmly applied to the cervix creates a significant risk for umbilical cord prolapse, which is a fetal emergency causing acute fetal hypoxemia due to cord compression. The immediate priority is to assess the fetal heart rate (FHR) and perform a sterile vaginal exam (SVE) to palpate for the prolapsed cord and assess the presenting part. FHR assessment detects distress; SVE detects the prolapse.