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.

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Correct Answer is B

Explanation

Choice A reason:

A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess ﬂuid accumulated during pregnancy.

Choice B reason:

A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.

Choice C reason:

Chills shortly following delivery are common and benign and are caused by hormonal changes and ﬂuid shifts.

Choice D reason:

A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

A. Apply ice packs to the perineal area several times daily. B. Sit on an inﬂatable donut to protect the perineum. C. Perform hand hygiene before and after voiding. D. Blot the perineal area dry after voiding. E. Clean the perineal area from front to back.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.

Choice B reason: Sit on an inﬂatable donut to protect the perineum is incorrect, as this can increase pressure and blood ﬂow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.

Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.

Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.

Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.

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

Correct Answer is B

Explanation

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

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A nurse is preparing to administer dinoprostone gel to a client who is pregnant. The client asks the nurse about the purpose of the medication. Which of the following responses should the nurse make?

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 caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

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 assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?