On the fourth postpartum day, a client experiences breast engorgement. To relieve her discomfort, which of these nursing interventions is most effective to meet the expected outcome?
Remove the client's bra
Alternate with warm compresses and ice packs to the breasts
Administer acetaminophen as prescribed
Limit breastfeeding to twice a day
The Correct Answer is B
A. Remove the client's bra: Incorrect. A well-fitted supportive bra helps reduce discomfort and swelling. Removing the bra may increase pain and worsen engorgement.
B. Alternate with warm compresses and ice packs to the breasts: Correct. Warm compresses before breastfeeding help with milk flow, and cold compresses after feeding reduce swelling and discomfort.
C. Administer acetaminophen as prescribed: Incorrect. While pain relief can help, it does not directly address the engorgement.
D. Limit breastfeeding to twice a day: Incorrect. Frequent breastfeeding or pumping is encouraged to relieve engorgement.
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Related Questions
Correct Answer is C
Explanation
A. This is expected immediately postpartum.
B. This is expected at 24 hours postpartum.
C. Immediately after birth, the fundus is at the level of the umbilicus. The uterus involutes (shrinks) approximately 1 cm (or 1 fingerbreadth) per day postpartum. 48 hours postpartum, the fundus should be 2 cm (or 2 fingerbreadths) below the umbilicus.
D. 3 cm below the umbilicus would be expected at 72 hours postpartum.
Correct Answer is B
Explanation
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
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