A breastfeeding patient who is 5 weeks postpartum calls the clinic and reports that she is achy all over, has a temperature of 100.2°F, and has pain and tenderness in her right breast. What is the nurse’s best response?

Correct Answer: A

Rationale: The correct answer is A) You need to come to the clinic to be evaluated, as your symptoms indicate a possible breast infection. This response is the best choice because the patient's symptoms of achiness, fever, and pain/tenderness in the breast are indicative of mastitis, a common breast infection in breastfeeding women. Prompt evaluation and treatment are crucial to prevent complications and ensure the mother's well-being. Option B) is incorrect because engorgement typically presents with breast fullness and discomfort, not generalized achiness and fever. While more frequent breastfeeding can help with engorgement, it is not the appropriate response to the symptoms described. Option C) is also incorrect as advising a mother to stop breastfeeding without proper evaluation can lead to decreased milk supply and potential complications for both the mother and baby. Breastfeeding can usually continue with proper management of mastitis. Option D) is incorrect as sleep deprivation may contribute to overall feelings of achiness and soreness but does not explain the localized symptoms in the right breast. It is essential to address the specific breast symptoms promptly in this scenario. In an educational context, this question highlights the importance of recognizing and managing common postpartum complications like mastitis in breastfeeding women. Nurses and healthcare providers must have a thorough understanding of postpartum care to provide appropriate guidance and support to new mothers. Early identification and intervention can improve outcomes and promote successful breastfeeding.

Correct Answer: A

Rationale: In postpartum hemorrhage leading to hematoma, rectal pain accompanied by a rising pulse (Option A) is a significant sign. This is because a hematoma is a localized collection of blood outside blood vessels, often causing pain in the affected area. The rising pulse indicates the body's response to increased blood loss, which is a critical sign of postpartum hemorrhage. Option B, cramping accompanied by a steady trickle of blood, is more indicative of normal postpartum contractions and bleeding. Option C, a soft uterine fundus and falling blood pressure, suggests uterine atony leading to hemorrhage but not specifically related to hematoma formation. Option D, heavy lochia accompanied by tachypnea and dyspnea, may indicate other complications like pulmonary embolism but does not directly point towards hematoma formation. Educationally, understanding the specific signs and symptoms of postpartum complications like hematoma is crucial for healthcare providers to provide timely and appropriate interventions to prevent further complications and ensure maternal well-being post-delivery. It is essential to differentiate between various postpartum complications to provide effective care and prevent adverse outcomes.

Correct Answer: D

Rationale: In the context of postpartum care, when a woman is receiving heparin therapy, it is crucial to have protamine sulfate readily available. Protamine sulfate is the antidote for heparin, a common anticoagulant used to prevent blood clots. If a woman on heparin therapy experiences excessive bleeding or needs urgent reversal of the anticoagulant effects, protamine sulfate can quickly neutralize the effects of heparin, thereby preventing serious complications like hemorrhage. Option A, Vitamin K, is not directly related to reversing the effects of heparin. Vitamin K is commonly used to treat coagulation disorders related to deficiencies in clotting factors, particularly in newborns. Option B, Methylergonovine, is a medication used to prevent or control postpartum hemorrhage by inducing uterine contractions. It is not indicated for reversing the effects of heparin therapy. Option C, Ferrous sulfate, is an iron supplement used to treat or prevent iron deficiency anemia. It is not relevant to the scenario of a woman on heparin therapy requiring an antidote. Understanding the appropriate antidotes and reversal agents for medications is essential in clinical practice, especially in situations where prompt intervention is necessary to ensure patient safety and optimal outcomes. Healthcare providers should be knowledgeable about the specific antidotes for commonly used medications to address potential complications effectively.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Reporting foul-smelling lochia and fever. This is crucial because the clinical presentation indicates a potential postpartum infection, most likely endometritis due to prolonged rupture of membranes and instrument-assisted delivery. Teaching this client to recognize signs of infection is vital for early intervention and prevention of complications. Option B) Delaying intercourse for at least 6 weeks is a standard recommendation postpartum but is not the priority in this case where infection signs are more critical to address promptly. Option C) Eating a diet high in iron and vitamin C is important for postpartum recovery but is not the priority when signs of infection are present, as addressing infection takes precedence. Option D) Losing weight over at least a 6-month period is not relevant to the immediate postpartum period and does not address the current clinical concern of potential infection. Educationally, this question highlights the importance of client education in recognizing and reporting postpartum complications, emphasizing the significance of early detection and intervention in improving outcomes for postpartum women. It underscores the need for healthcare providers to educate clients on signs and symptoms to watch for after childbirth, promoting their active participation in their own postpartum care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Tell the father to call the physician immediately and not to leave the woman alone with the baby. This response is crucial because the mother is displaying symptoms of postpartum psychosis, a serious condition that requires immediate medical attention. Postpartum psychosis can pose a risk to both the mother and the baby's safety. By advising the father to contact the physician, the nurse ensures that the mother receives the necessary medical intervention promptly. Option A is incorrect because dismissing the symptoms as postpartum blues and suggesting they will pass with support is dangerous in this case of potential psychosis. Option B is inadequate as the situation requires urgent medical attention rather than casual conversation. Option C, while acknowledging the need for psychotherapy, falls short of the immediate action needed to address the severity of the mother's symptoms. Educationally, this scenario highlights the importance of recognizing and responding to postpartum mental health issues promptly. Nurses and healthcare providers must be vigilant in assessing and addressing postpartum complications to ensure the well-being of both the mother and the baby. Early intervention and appropriate referrals can significantly impact the outcomes for families experiencing postpartum mental health challenges.