A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery.
Which of the following actions should the nurse take?

Choice C rationale:

Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,

affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after

childbirth, but they can sometimes take up to a week to appear.

Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid

buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.

Choice A rationale:

An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be

caused by many other factors, such as fever, dehydration, and anxiety.

Choice B rationale:

Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused

by many other factors, such as pain, fatigue, and nausea.

Choice D rationale:

Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,

medications, and underlying medical conditions.

Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.

Choice A rationale:

When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the

darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.

The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see

much more of the darker nipple skin above the baby’s top lip than below their bottom lip.

Choice B rationale:

While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper

positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to

ineffective breastfeeding and potential discomfort for the mother.

Choice C rationale:

The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the

baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the

nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.

Choice D rationale:

While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during

breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep

latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.