Exhibits

The nurse determines the need to perform more of an assessment based on the client's symptoms.

Based on the new assessment findings, choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

Based on the assessment findings, the priority diagnosis suspected is 

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This diagnosis places the client at risk of

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A. After a feeding, the nipple is creased. A creased nipple suggests a poor latch, which can lead to ineffective milk removal and increase the risk of recurrent mastitis. A proper latch should be deep, with the baby covering a large portion of the areola, ensuring effective drainage of the breast.
B. The feelings of fatigue continue, but there are no chills, achiness, or dizziness. While the absence of chills, achiness, and dizziness indicates improvement, persistent fatigue may suggest anemia, inadequate hydration, or continued recovery from infection. Fatigue alone does not confirm complete resolution of mastitis.
C. The infant continues to want to nurse all the time. Cluster feeding can be normal during growth spurts, but persistent frequent feeding beyond 2–3 hours may indicate poor milk transfer, low supply, or ineffective latch. Mastitis resolution should result in more effective milk drainage and a more predictable feeding pattern.
D. The temperature taken at home is 99.0° F (37.2° C). A normal temperature suggests that the infection and systemic inflammation have resolved. Mastitis is characterized by fever, so its absence indicates improvement.
E. Pain during feeding lasts for 10 of the 20 minutes of the feed. Persistent pain, especially for half the feeding duration, may indicate ongoing inflammation, nipple trauma, or unresolved infection. Resolution of mastitis should lead to pain-free or minimal discomfort during feeding.
F. Pumping continues on the right side instead of breastfeeding on that side. If the affected breast is still too painful for direct nursing, this suggests ongoing inflammation or poor resolution of mastitis. Ideally, the mother should be able to comfortably breastfeed from both breasts.
G. The red area on her right breast has resolved. The disappearance of redness, swelling, and warmth indicates resolution of localized inflammation and infection, confirming improvement in mastitis.
H. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions. Effective breastfeeding frequency and positioning ensure proper milk drainage, reducing the risk of recurrence. Mastitis resolution should allow the mother to comfortably breastfeed at regular intervals with different holds to promote complete emptying of all milk ducts.

A. Palpate femoral pulses. While assessing pulses is important in circulation checks, femoral pulses are located proximally and may not accurately reflect distal circulation in the casted limb. Checking pulses in the lower extremities, such as the dorsalis pedis or posterior tibial pulses, would be more relevant.
B. Compare temperature of both legs. Temperature comparison can help detect circulatory compromise, but it is a less immediate and less specific indicator than capillary refill. A leg may feel cool due to prolonged exposure rather than poor perfusion, making capillary refill a more reliable assessment.
C. Monitor capillary refill of the toes. Capillary refill is a critical assessment for adequate circulation in a child with a cast. Delayed capillary refill (greater than 2 seconds) may indicate compromised blood flow, which could result from excessive cast tightness or compartment syndrome, requiring immediate intervention.
D. Examine for spontaneous movement. Assessing movement is important in evaluating nerve function, but it does not directly assess vascular compromise, which is the most immediate concern in a newly applied cast. Lack of movement could indicate nerve damage but is not the primary priority over circulation assessment.