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.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A reason:
A blood glucose level of 96 mg/dL is within the normal range for a fasting blood sugar level in pregnancy, which is typically between 70 to 95 mg/dL. It is crucial to monitor blood glucose levels during pregnancy due to the risk of gestational diabetes, which can have adverse effects on both the mother and the fetus.

Choice B reason:
The production of estrogen is indeed enhanced during pregnancy. Estrogen plays a vital role in maintaining the pregnancy, promoting fetal development, and preparing the body for childbirth. Elevated levels of estrogen are expected and contribute to many of the physiological changes experienced during pregnancy.

Choice C reason:
A heart rate of 120 bpm (beats per minute) can be considered slightly elevated during pregnancy. The normal resting heart rate for a pregnant woman is usually between 60 to 100 bpm. However, during pregnancy, the heart rate can increase to accommodate the increased blood volume and the needs of the growing fetus. Given the information provided, the most likely scenario that the nurse should address is the heart rate of 120 bpm, as it is slightly above the normal range and may need monitoring or intervention.

Choice D reason:
Weakened respiratory contractions are not typically expected during pregnancy. Pregnant women may experience shortness of breath due to the growing uterus pushing against the diaphragm, but the respiratory contractions themselves should not be weakened. If this occurs, it may warrant further investigation.

A. "It detects positive antibodies in the mother's blood." B. "It detects Rh-negative antibodies in the newborn's blood." C. "It determines if kernicterus will occur in the newborn." D. "It determines the presence of maternal antibodies in the newborn's blood."

Correct Answer is A

Explanation

Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.

Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.

Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.

Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 28 weeks of gestation and has:

Correct Answer is C

Explanation

A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

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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?

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A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

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