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 B
Explanation
Choice B reason:
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. The client is at risk for uterine atony due to delivering a large newborn, which can overstretch the uterine muscles and reduce their tone.
Choice A reason:
Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery. The client is not at increased risk for puerperal infection due to delivering a large newborn, unless there are other factors such as prolonged labor, multiple vaginal exams, or episiotomy.
Choice C reason:
Thrombophlebitis is an inflammation of a vein with a blood clot formation. The client is not at increased risk for thrombophlebitis due to delivering a large newborn, unless there are other factors such as immobility, dehydration, or trauma.
Choice D reason:
Retained placental fragments are pieces of the placenta that remain in the uterus after delivery, which can cause bleeding and infection. The client is not at increased risk for retained placental fragments due to delivering a large newborn, unless there are other factors such as abnormal placental atachment, manual removal, or incomplete separation.
Correct Answer is D
Explanation
Choice A reason: Position the client on her left side is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Positioning the client on her left side can enhance uterine blood flow and placental perfusion, but it does not address the cause of uterine atony or bladder distension.
Choice B reason: Encourage the client to perform Kegel exercises is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Kegel exercises can strengthen the pelvic floor muscles and prevent urinary incontinence, but they do not affect the uterine tone or position.
Choice C reason: Ask the client to rate her pain is incorrect, as this action is not a priority for a client who has a boggy and displaced fundus. Asking the client to rate her pain can provide information about the need for analgesics, but it does not address the risk of hemorrhage or infection due to uterine atony or bladder distension.
Choice D reason: Assist the client to the bathroom to void is correct, as this action can resolve the problem of a boggy and displaced fundus. A boggy and displaced fundus indicates uterine atony and bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and then massage the fundus until it becomes firm and midline.
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