The nurse is teaching the postpartum mother who is ready for discharge.
The nurse reminds her to take the extra peripads home with her.
The client states, "Oh, I don't use those.
I always use tampons.”. Which of the following actions by the nurse is appropriate at this time?
Advise the client that for the next several days she will be bleeding too heavily for a tampon.
Get her a supply of tampons to take home.
The Correct Answer is D
Choice A rationale
The use of tampons is not recommended due to the risk of infection, regardless of the amount of bleeding. The uterine lining is shedding, and the cervix is open, creating a direct pathway for bacteria to enter the sterile uterine cavity, potentially leading to endometritis or toxic shock syndrome.
Choice B rationale
Providing tampons to the client would be an unsafe nursing action. It is crucial to educate the client on the risks associated with tampon use during the postpartum period due to the open wound at the placental site and the dilated cervix, which can lead to serious infections.
Choice C rationale
While a tampon may be uncomfortable, the primary reason to avoid their use is not the pain or discomfort. The main concern is the risk of introducing bacteria into the uterus, which is highly susceptible to infection postpartum due to the open placental site and lochia.
Choice D rationale
It is unsafe to place anything in the vagina for the first six weeks after birth because the placental insertion site is an open wound, and the cervix remains slightly dilated, providing a direct route for bacteria to ascend into the uterus, which could lead to severe infection such as endometritis. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A fundus located just above the umbilicus is a finding that would be expected immediately after birth, not 6 hours postpartum. The uterus begins to descend back into the pelvis at a rate of approximately 1 cm per day, so it would already have descended from its immediate post-birth position.
Choice B rationale
The fundus is not palpable abdominally in an uncomplicated postpartum recovery typically after 10 days, when it has descended back into the true pelvis. At 6 hours postpartum, it is still very much palpable and is a key parameter for monitoring uterine involution and assessing for potential postpartum hemorrhage.
Choice C rationale
The fundus is expected to be approximately 1-2 cm below the umbilicus at 12 hours postpartum. At 6 hours postpartum, it would be close to or slightly below the umbilicus. A location of two centimeters below the umbilicus is an expected finding due to the normal process of uterine involution.
Choice D rationale
A fundus located midway between the umbilicus and the symphysis pubis is the expected location at about one week postpartum, not 6 hours. This reflects the steady descent of the uterus back to its pre-pregnancy size and location within the pelvic cavity, a process known as involution.
Correct Answer is C
Explanation
Choice A rationale
Expressing small amounts of milk may provide temporary relief but stimulates further milk production, which will worsen breast engorgement. The goal is to reduce milk production, not encourage it, as the woman has decided to bottle-feed. Applying cold compresses or tight support bras are more appropriate interventions because they help to constrict blood vessels and reduce swelling and discomfort without promoting additional lactation.
Choice B rationale
Wearing a loose-fitting bra will not provide the necessary support to compress the breasts, which is essential for reducing milk production and discomfort associated with engorgement. A tight, supportive bra, or even a binder, is recommended to apply gentle, even pressure to the breast tissue. This compression helps to inhibit lactation and provides significant relief from the pain and swelling of breast engorgement.
Choice C rationale
Applying ice or cold packs to the breasts is the best treatment. Cold therapy causes vasoconstriction, which helps to reduce blood flow, swelling, and inflammation in the breasts. This not only provides significant pain relief and comfort but also helps to inhibit further milk production. The application of cold packs for 15-20 minutes, several times a day, is an effective strategy for managing breast engorgement in a woman who is not breastfeeding.
Choice D rationale
Running warm water on the breasts will cause vasodilation, which increases blood flow and can stimulate the let-down reflex. This action will increase milk production and worsen the symptoms of breast engorgement. Therefore, this is a contraindicated intervention for a woman experiencing engorgement who has chosen to bottle-feed. The warmth would exacerbate her discomfort and the underlying physiological process she is trying to resolve
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