A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Mastitis. Mastitis is an infection of the breast tissue that can occur due to various factors, including retained placental fragments. In this case, the retained placental fragments can lead to an infection, causing inflammation and pain in the affected breast. Common symptoms of mastitis include redness, warmth, swelling, and tenderness in the breast, accompanied by flu-like symptoms such as fever and body aches. Option A) Engorgement is incorrect because engorgement typically occurs when the breasts become overly full with milk, leading to swelling and discomfort, but it is not directly related to retained placental fragments causing an infection. Option C) Blocked milk duct is incorrect as it occurs when milk is unable to flow freely within the duct, often due to pressure on the duct, but it is not specifically associated with an infection caused by retained placental fragments. Option D) Low milk supply is incorrect in this context because retained placental fragments leading to mastitis would not directly impact milk production. Low milk supply can be influenced by various factors such as inadequate breastfeeding or hormonal issues, but it is not the expected complication in this scenario. Educationally, understanding the potential complications of retained placental fragments in breastfeeding women is crucial for nurses and healthcare providers to provide appropriate care and support. Recognizing the signs and symptoms of mastitis, differentiating it from other breastfeeding issues, and initiating prompt treatment are essential in ensuring the well-being of both the mother and the infant. This knowledge helps in promoting successful breastfeeding outcomes and maternal health postpartum.

Correct Answer: B

Rationale: The correct answer is B) "I'll take him to a specialist. Then he will get better." This statement suggests that the client is in the bargaining phase of grief where they are trying to negotiate or make deals to reverse the situation. This response shows a sense of hope and a belief that seeking medical help will lead to improvement in the baby's condition. Option A) "I hate myself. I caused my baby to be sick" indicates guilt and self-blame, which align more with the guilt phase of grief. Option C) "I can't seem to stop crying" suggests overwhelming sadness, which is characteristic of the depression phase of grief. Option D) "This can't be happening" reflects denial, which is common in the initial stages of grief. In an educational context, understanding the stages of grief can help healthcare providers support clients experiencing loss or challenging situations. Recognizing these stages can guide effective communication and provide appropriate emotional support to clients during the postpartum period. It is crucial for healthcare professionals to be aware of these emotional responses and be prepared to offer empathy, understanding, and resources to help clients navigate through their grief process.

Correct Answer: B

Rationale: In the context of managing heparin overdose, the correct medication to have on hand is B) Protamine. Protamine is a specific antidote for heparin and works by binding to heparin to form a stable complex, neutralizing its anticoagulant effects. This action helps to reverse the anticoagulant activity of heparin, making it crucial in cases of heparin overdose to prevent excessive bleeding. Option A) Vitamin K is used to reverse the effects of warfarin, a different type of anticoagulant, not heparin. Option C) Vitamin E has no direct role in reversing heparin overdose. Option D) Mannitol is a diuretic used to reduce intracranial pressure or treat oliguric renal failure; it is not indicated for heparin overdose. In an educational context, understanding the antidotes for common medications is vital for nurses to provide safe and effective care. Knowing the specific antidotes for medications like heparin can help nurses act promptly in emergency situations, ensuring the best outcomes for their patients. Protamine administration requires precise dosing and monitoring due to the risk of adverse reactions, emphasizing the importance of accurate medication administration and vigilant patient assessment.

Correct Answer: B

Rationale: In this scenario, the correct action by the nurse before starting the blood transfusion is to check the client's arm bracelet (Option B). This is critical because the arm bracelet typically contains the client's unique identification information, including their name and a specific patient identification number. Verifying this information ensures that the blood transfusion is given to the correct patient, reducing the risk of a potentially life-threatening transfusion reaction due to mismatched blood. Checking the client's blood type in the chart (Option A) is important for identifying the compatibility of the blood to be transfused but is not as immediately critical as verifying the patient's identity. Checking the blood type on the infusion bag (Option C) is also important but does not address the immediate need to confirm the patient's identity. Obtaining an infusion bag of dextrose and water (Option D) is incorrect as it does not pertain to the process of ensuring the safety and accuracy of the blood transfusion. In an educational context, emphasizing the importance of patient identification and verification procedures before any invasive or high-risk procedure is crucial in nursing practice. This ensures patient safety, prevents medical errors, and upholds the standards of care and professional responsibility in healthcare settings. Nurses must always follow proper protocols to verify patient identity and match it with the intended treatment or intervention to prevent adverse events and promote positive patient outcomes.

Correct Answer: B

Rationale: In this scenario, option B is the correct answer. The client's blood pressure dropping from 160/120 to 130/90 indicates that the hydralazine is effectively managing the hypertension associated with eclampsia. This is a crucial indicator of the medication's effectiveness as controlling blood pressure is a priority in postpartum care for clients with eclampsia to prevent complications like seizures and strokes. Option A is incorrect because the absence of seizures could be due to other factors, not necessarily the effectiveness of hydralazine. Option C is unrelated to the medication's effectiveness and may be attributed to factors like fluid loss after delivery. Option D is also incorrect as the resolution of a headache is not a direct indicator of hydralazine's effectiveness in managing hypertension. Educationally, understanding the rationale behind monitoring blood pressure in postpartum clients with eclampsia and interpreting the effectiveness of antihypertensive medications is crucial for providing safe and effective care to this vulnerable population. This question highlights the importance of assessing specific parameters to evaluate the effectiveness of pharmacological interventions in postpartum management.