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The nurse is educating a postpartum woman on how to prevent engorgement. Which action of the patient indicates effective learning?
- A. Breastfeeding the infant every 2 to 3 hours
- B. Avoiding using soap on the breast when bathing
- C. Drinking 8 to 10 glasses of water during the day
- D. Binding the breast with a towel or stretch bandage
Correct Answer: A
Rationale: The correct answer is A because breastfeeding the infant every 2 to 3 hours helps to empty the breasts regularly, preventing engorgement. This frequent breastfeeding stimulates milk production and prevents milk stasis. Choice B is incorrect as avoiding soap on the breast during bathing is unrelated to preventing engorgement. Choice C is also incorrect as hydration is important, but it does not directly prevent engorgement. Choice D is incorrect as binding the breast with a towel or stretch bandage can lead to further engorgement by restricting milk flow.
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A breastfeeding postpartum woman tells the nurse, "I am not sure I want to breastfeed because I notice that when I feed my baby, I have strong contraction-like pain. Is something wrong?" Which response by the nurse is most appropriate?
- A. "I will call the doctor and let him know your concern."
- B. "You may be getting an infection and will have to stop breastfeeding."
- C. "This is normal because your uterus is shrinking back to the normal size."
- D. "The baby's sucking during breastfeeding releases the hormone oxytocin, which stimulates the uterus to contract."
Correct Answer: D
Rationale: The correct answer is D. Oxytocin is a hormone that is released during breastfeeding in response to the baby's sucking, causing the uterus to contract. This helps the uterus return to its pre-pregnancy size and reduces postpartum bleeding. Choice A is incorrect as the issue does not require immediate doctor intervention. Choice B is incorrect as pain does not necessarily indicate infection. Choice C is incorrect as it does not explain the role of oxytocin in uterine contractions during breastfeeding.
A nurse is preparing to perform a fundal assessment on a postpartum client who delivered 12 hours ago. What should the nurse do first?
- A. Lower the head of the bed
- B. Locate the level of the fundus
- C. Assist the woman to the bathroom to empty her bladder
- D. Massage the fundus
Correct Answer: C
Rationale: The correct first step is to assist the woman to the bathroom to empty her bladder. This is important to ensure an accurate fundal assessment, as a full bladder can displace the uterus and lead to incorrect fundal height measurement. Lowering the head of the bed (Choice A) is not necessary for a fundal assessment. Locating the level of the fundus (Choice B) should come after ensuring the bladder is empty. Massaging the fundus (Choice D) is not indicated until after the fundal assessment is completed.
The nurse is educating a postpartum woman on how to prevent engorgement. Which action of the patient indicates effective learning?
- A. Breastfeeding the infant every 2 to 3 hours
- B. Avoiding using soap on the breast when bathing
- C. Drinking 8 to 10 glasses of water during the day
- D. Binding the breast with a towel or stretch bandage
Correct Answer: A
Rationale: The correct answer is A because breastfeeding the infant every 2 to 3 hours helps in emptying the breasts regularly, preventing engorgement. This frequent feeding stimulates milk production and prevents milk buildup. Choice B is incorrect as soap can dry out the skin, leading to cracked nipples. Choice C is important for overall hydration but not directly related to preventing engorgement. Choice D is incorrect as binding the breast can lead to blocked milk ducts and worsen engorgement.
A nurse is preparing to perform a fundal assessment on a postpartum client who delivered 12 hours ago. What should the nurse do first?
- A. Lower the head of the bed
- B. Locate the level of the fundus
- C. Assist the woman to the bathroom to empty her bladder
- D. Massage the fundus
Correct Answer: C
Rationale: The correct answer is C because assisting the woman to the bathroom to empty her bladder is the first step in a fundal assessment. A full bladder can displace the uterus and affect fundal height accuracy. Lowering the head of the bed (A) is not necessary for this assessment. Locating the level of the fundus (B) should come after ensuring the bladder is empty. Massaging the fundus (D) is not the initial step and could be harmful if the bladder is full.
The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema, Ecchymosis, Discharge, and Approximation, focusing on physical characteristics. Pain assessment is important but not part of the REEDA visual assessment. Perineal coloration (A), suture line appearance (B), and amount of swelling (C) are all physical aspects covered by REEDA.