A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A white patch on a nipple

Red and painful area in one breast

Cracked and bleeding nipples

Swelling in both breasts

Answer and Explanation

The Correct Answer is B

A) A white patch on a nipple:

A white patch on the nipple may indicate a condition such as a milk bleb or a fungal infection like thrush, but it is not characteristic of mastitis. Mastitis typically presents with localized redness and pain in the affected breast, along with other systemic symptoms such as fever and flu-like symptoms.

B) Red and painful area in one breast:

This finding is indicative of mastitis. Mastitis is an inflammation of the breast tissue, often caused by bacterial infection, which presents with localized redness, warmth, swelling, and pain in one breast. The affected area may also feel tender or hard to the touch.

C) Cracked and bleeding nipples:

Cracked and bleeding nipples are common in breastfeeding mothers, but they are not specific signs of mastitis. However, they can increase the risk of mastitis if bacteria enter the breast tissue through the cracked skin. Proper breastfeeding techniques and nipple care can help prevent nipple damage and reduce the risk of mastitis.

D) Swelling in both breasts:

Swelling in both breasts may occur in the early postpartum period due to engorgement or increased milk production, but it is not a specific sign of mastitis. Mastitis typically presents with localized symptoms in one breast rather than both breasts simultaneously.

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Correct Answer is A

Explanation

A) 48/min:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal range for respiratory rate in newborns is typically between 30 to 60 breaths per minute.

B) 100/min:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. While newborns may exhibit slightly elevated respiratory rates, a rate of 100 breaths per minute is higher than usual and may warrant further assessment.

C) 22/min:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Normal respiratory rates for newborns are typically higher than 22 breaths per minute.

D) 110/min:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. Such a high respiratory rate may indicate respiratory distress or another underlying issue and requires prompt assessment and intervention.

A. Hold the newborn vertically allowing one foot to touch the table surface. B. Perform a sharp hand clap near the infant. C. Place a finger at the base of the newborn's toes. D. Turn the newborn's head quickly to one side.

Correct Answer is B

Explanation

A) Hold the newborn vertically allowing one foot to touch the table surface:

This action describes eliciting the Babinski reflex, not the Moro reflex. The Babinski reflex is elicited by stroking the sole of the foot, causing the toes to fan out and the big toe to dorsiflex while the other toes fan out.

B) Perform a sharp hand clap near the infant:

This action correctly describes eliciting the Moro reflex. The Moro reflex, also known as the startle reflex, is elicited by a sudden movement or loud noise near the infant. The infant responds by extending the arms outward, then bringing them together as if embracing.

C) Place a finger at the base of the newborn's toes:

This action describes eliciting the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex is elicited by stimulating the sole of the foot, causing the toes to curl downward in a grasping motion.

D) Turn the newborn's head quickly to one side:

This action describes eliciting the tonic neck reflex, also known as the fencing reflex, not the Moro reflex. The tonic neck reflex is elicited by turning the infant's head to one side while they are lying supine, causing the limbs on the side the head is turned toward to extend, and the limbs on the opposite side to flex.

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A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

Nursing Test Bank

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A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?