Exhibits

Review H and P, and nurse's note.

Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.

• Mastitis: Mastitis is an infection of breast tissue that occurs when milk stasis leads to bacterial overgrowth, usually caused by Staphylococcus aureus. The client's firm, red, warm area on the breast, fever (101.2°F), chills, body aches, and fatigue all strongly indicate mastitis rather than other breast conditions.
• Engorgement: Engorgement occurs when the breasts overfill with milk, leading to swelling and tenderness. However, engorgement typically affects both breasts, does not cause fever or flu-like symptoms, and resolves with regular breastfeeding or pumping.
• Blocked milk duct: A clogged duct occurs when milk flow is obstructed, leading to a tender lump in the breast. While a blocked duct can progress to mastitis, it does not cause fever or systemic symptoms unless infection develops. The presence of fever and flu-like symptoms in this client suggests mastitis, not just a blocked duct.
• Inflammatory breast cancer: This rare but aggressive form of breast cancer causes redness, swelling, and skin thickening, but it is not associated with fever or acute symptoms like mastitis. It does not develop suddenly but rather progresses over time, making mastitis the more likely diagnosis in this case.
• Abscess: If mastitis is not treated promptly, it can lead to a breast abscess, a localized collection of pus requiring drainage. Signs of progression to an abscess include fluctuant swelling, worsening pain, and persistent fever despite antibiotic treatment.
• Breastfeeding intolerance: Mastitis can cause temporary discomfort during breastfeeding, but it does not lead to true breastfeeding intolerance. In fact, continued breastfeeding helps resolve mastitis by improving milk drainage.
• Nipple thrush: Nipple thrush (Candida infection) causes burning pain and white patches in the infant’s mouth but is not a complication of mastitis, which is bacterial, not fungal.
• Postpartum haemorrhage: Postpartum hemorrhage is caused by uterine atony, retained placenta, or coagulation disorders, not mastitis. Mastitis is localized to the breast and does not affect uterine bleeding.

A. Heat loss. Newborns are highly susceptible to heat loss due to their large surface area relative to body weight and limited ability to generate heat. Cold stress can lead to hypoglycemia, respiratory distress, and metabolic acidosis. To prevent this, the nurse should dry the newborn thoroughly, provide skin-to-skin contact, and use a radiant warmer or warm blankets immediately after birth.
B. Fluid balance. While newborns require close monitoring of fluid balance, they are born with sufficient fluid stores. Dehydration is not an immediate concern within the first few minutes of life. Initial interventions focus on thermoregulation and establishing respiration.
C. Bleeding tendencies. Newborns have low vitamin K levels, which increase the risk of bleeding. However, vitamin K prophylaxis is given within the first hour after birth and is not the immediate priority over establishing adequate oxygenation and thermoregulation.
D. Hypoglycemia. Hypoglycemia is a concern, especially in infants of diabetic mothers or those with low birth weight. However, preventing heat loss is a higher priority, as cold stress can contribute to hypoglycemia. Once thermoregulation is established, glucose monitoring can be performed as needed.