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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

A. Fetal position is persistent occiput posterior. B. Fetal attitude is in general ﬂexion. C. Fetal lie is longitudinal. D. Maternal pelvis is gynecoid.

Correct Answer is A

Explanation

Choice A reason:
Fetal position is persistent occiput posterior is correct, as this position can cause difficult, prolonged labor and severe backache. The occiput posterior position means that the back of the fetal head is facing the maternal sacrum, which can result in poor alignment and descent, increased pressure on the maternal sacrum and nerves, and increased risk of perineal trauma. The nurse should encourage the client to change positions frequently, use pelvic rocking exercises, apply counterpressure to the sacrum, and administer analgesics as needed.

Choice B reason:
Fetal attitude is in general ﬂexion is incorrect, as this attitude can facilitate normal labor and delivery. The fetal attitude refers to the degree of ﬂexion or extension of the fetal head and limbs in relation to the fetal trunk. General ﬂexion means that the fetal head is ﬂexed on the chest, the arms are crossed over the chest, and the legs are ﬂexed at the knees. This attitude allows the smallest diameter of the fetal head to pass through the birth canal.

Choice C reason:
Fetal lie is longitudinal is incorrect, as this lie can facilitate normal labor and delivery. The fetal lie refers to the relationship between the long axis of the fetus and the long axis of the mother. Longitudinal lie means that both axes are parallel, which allows for either a vertex (head-first) or a breech (butocks-first) presentation.

Choice D reason:
Maternal pelvis is gynecoid is incorrect, as this pelvis can facilitate normal labor and delivery. The maternal pelvis refers to the shape and size of the bony pelvis that aﬀects the passage of the fetus. Gynecoid pelvis is the most common and favorable type for vaginal birth, as it has a rounded inlet, a wide pubic arch, and adequate outlet dimensions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

A nurse is assisting in the care of a client who had a vaginal birth 2 hr ago. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV ﬂuids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?