The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action?
The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action?
A. Perform a vaginal examination
[13%]
B. Prepare the client for a pelvic ultrasound
[10%]
C. Reassure the client that this is a normal finding
[74%]
D. Instruct the client to bottle feed the infant until the sensation subsides
[2%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Postpartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Analysis
Explanation
Choice C is correct. Breastfeeding causes the release of oxytocin which stimulates uterine contractions. The client may describe a cramping type of sensation which is expected. The cramping sensation is generally strongest two to three days postpartum.
Choices A, B, and D are incorrect. None of these actions are appropriate for the nurse to take because this is a normal physiological response. Oxytocin is released from the posterior pituitary gland and is released with nipple stimulation. It is not advised that the client bottle feed the infant because this could create nipple confusion and make latching for breastfeeding challenging.
Additional Info
✓ Breastfeeding provides several key advantages, such as a lower risk of the infant developing SIDS, asthma, and other disorders.
✓ The client should wear a supportive bra with no underwire.
✓ The infant should milk on demand until the breast softens. Each feeding should last between 15-20 minutes.
✓ For breastfeeding, the client should start with the breast with which the last feeding ended.
✓ The client should be positioned in football or clutch hold; the mother supports the infant's head and neck in her hand, with the infant's body resting on pillows alongside her hip.
✓ The cross-cradle or modified cradle hold is helpful for preterm infants or fractured clavicles. The mother holds the infant's head with the hand opposite the side on which the infant will feed and supports the infant's body across her lap with her arm.
✓ The side-lying position avoids pressure on episiotomy or abdominal incisions and allows the mother to rest while feeding. She lies on her side, with her lower arm supporting her head or placed around the infant. Pillows behind her back and between her legs provide comfort.
✓ A hungry infant usually opens the mouth, but some need a minute of stroking the area around the mouth.
✓ The nurse should note that most of the areola on the underside is covered by the baby's mouth; some of the areola on the top side may be visible.
✓ A soft “ka” or “ah” sound indicates the infant is swallowing colostrum or milk.
✓ Teach the mother to remove the infant from the breast if the suckling becomes painful.
✓ Providing continuous support to the mother (who may be nervous) is essential to successful breastfeeding.
