A postpartum client is breastfeeding and expresses discomfort during feedings due to sore nipples. What nursing intervention should be prioritized to alleviate nipple soreness?

Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.

Correct Answer: A

Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.

Correct Answer: C

Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.

Correct Answer: C

Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.