A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?

The client is exhibiting early indications of mastitis.

Additional interventions are not indicated at this time.

The client should be advised to remove her nursing bra.

Application of a heating pad to the breasts is indicated.

Answer and Explanation

The Correct Answer is B

Choice a reason:
Mastitis is an infection of the breast tissue that results in pain, swelling, warmth, and redness. The symptoms of mastitis typically include breast tenderness, redness on the skin, breast pain, and sometimes fever and malaise. While the client's breasts are described as hard and warm, which could be associated with mastitis, the absence of other key symptoms such as fever or flu-like symptoms suggests that mastitis may not be the issue here.

Choice b reason:
Three days postpartum, it is normal for the fundus to be below the umbilicus and for lochia rubra to be present. The hardness and warmth of the breasts could be due to milk coming in, which is also a normal postpartum change. Without additional symptoms of concern, such as fever, severe pain, or signs of infection, it is reasonable to conclude that no additional interventions are required at this time.

Choice c reason:
Removing a nursing bra can provide comfort, especially if it is too tight and contributing to breast engorgement or clogged ducts. However, there is no indication that the client's nursing bra is causing an issue. Nursing bras are designed to support the breasts during breastfeeding and typically do not need to be removed unless they are causing specific problems.

Choice d reason:
Applying a heating pad can help with milk let-down and relieve discomfort from engorgement or clogged ducts. However, since the client is not exhibiting signs of mastitis or severe engorgement, and the warmth of the breasts may be due to normal postpartum changes, the application of a heating pad is not necessarily indicated at this time.

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Correct Answer is A

Explanation

Choice a reason:
Elevated blood pressure is a primary indicator for preeclampsia, which is a condition characterized by hypertension and often proteinuria after 20 weeks of gestation. The criteria for hypertension in pregnancy are a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least 4 hours apart. If a pregnant client presents with elevated blood pressure, it is crucial for the nurse to initiate further evaluation for preeclampsia, as this condition can lead to serious complications for both the mother and the fetus.

Choice b reason:
Joint pain is not a typical sign of preeclampsia. While joint pain can be a symptom experienced during pregnancy due to various physiological changes, it is not specifically associated with preeclampsia and does not warrant further evaluation for this disorder on its own.

Choice c reason:
Vaginal discharge during pregnancy is common and can vary in consistency and amount. It is not a specific indicator of preeclampsia unless accompanied by other symptoms such as elevated blood pressure or proteinuria. Normal vaginal discharge is usually clear or milky white and does not indicate the need for preeclampsia evaluation.

Choice d reason:
Increased urine output is not typically associated with preeclampsia. In fact, preeclampsia can sometimes lead to reduced urine output due to kidney impairment. If a client has increased urine output, it may be due to other factors such as increased fluid intake or gestational diabetes.

A. Increased subcutaneous fat B. Scant scalp hair C. Dry, cracked skin D. Copious vernix

Correct Answer is C

Explanation

The correct answer is choice C. Dry, cracked skin.

Choice A rationale:

Increased subcutaneous fat is more commonly seen in full-term infants, but post-term infants (born after 42 weeks) often have decreased subcutaneous fat due to the aging placenta’s reduced efficiency in nutrient delivery.

Choice B rationale:

Scant scalp hair is typically seen in preterm infants. Post-term infants usually have more developed features, including more scalp hair.

Choice C rationale:

Dry, cracked skin is a common finding in post-term infants because the protective vernix caseosa, which covers the skin in utero, has often been shed by this stage. The prolonged exposure to amniotic fluid can lead to skin that appears dry, cracked, and peeling.

Choice D rationale:

Copious vernix is usually seen in preterm infants. By 42.5 weeks, most of the vernix has been absorbed or shed, leading to the dry skin observed in post-term infants.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer is A

Explanation

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply)

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

A nurse is teaching a newborn's parent how to care for the umbilical cord stump. Which of the following instructions should the nurse include?

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

A nurse is caring for a client who is at 40 weeks of gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?