A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis?
Swelling in both breasts
Cracked and bleeding nipples
Increase in breast milk
Red and painful area in one breast
The Correct Answer is D
Choice A reason: Swelling in both breasts is incorrect, as this finding does not indicate mastitis. Swelling in both breasts can occur due to engorgement, which is a normal and expected phenomenon in the first few days after birth or when milk production increases. Engorgement can cause breast fullness, tenderness, and warmth, but it does not cause infection or inflammation.
Choice B reason: Cracked and bleeding nipples is incorrect, as this finding does not indicate mastitis. Cracked and bleeding nipples can occur due to poor latch, improper positioning, or excessive suction of the baby. Cracked and bleeding nipples can cause pain, discomfort, and risk of infection, but they do not cause mastitis by themselves.
Choice C reason: Increase in breast milk is incorrect, as this finding does not indicate mastitis. Increase in breast milk can occur due to hormonal changes, frequent breastfeeding, or stimulation of the breasts. Increase in breast milk can cause engorgement, but it does not cause infection or inflammation.
Choice D reason: Red and painful area in one breast is correct, as this finding indicates mastitis. Mastitis is an infection and inflammation of the breast tissue that usually affects one breast at a time. Mastitis can cause redness, pain, swelling, warmth, and fever in the affected breast. Mastitis can occur due to blocked milk ducts, bacterial invasion, or poor hygiene. The nurse should advise the client to continue breastfeeding or pumping, apply warm compresses, massage the breast gently, and take antibiotics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D reason: A client who has preeclampsia and reports epigastric pain and unresolved headache should be reported to the RN immediately, as these are signs of severe preeclampsia and impending eclampsia, which can lead to seizures, coma, and death. The client may need anticonvulsant medication, magnesium sulfate infusion, and delivery of the fetus.
Choice A reason: A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful may have preterm labor, which should be monitored and treated accordingly. However, this is not as urgent as choice D, as the contractions may subside with hydration, rest, or tocolytic medication.
Choice B reason: A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria may have mild preeclampsia, which should be managed with antihypertensive medication, bed rest, and fetal monitoring. However, this is not as urgent as choice D, as the reflexes and proteinuria are not indicative of severe preeclampsia or eclampsia.
Choice C reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors may have a common side effect of terbutaline, which is a beta-adrenergic agonist that relaxes uterine smooth muscle and inhibits contractions. However, this is not as urgent as choice D, as the tremors are usually transient and benign. The nurse should monitor the client's vital signs, blood glucose, and fetal heart rate.
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
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