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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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

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.

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Correct Answer is ["A","D","E","F","G"]

Explanation

A. Rupture of membranes for 16 hours – The risk of postpartum infection, particularly endometritis, increases with prolonged rupture of membranes because bacteria can ascend into the uterus after the amniotic sac is broken. Although infection risk is higher after 18 hours, 16 hours still poses a concern, especially when combined with other signs of infection.
B. Normal spontaneous vaginal birth – A vaginal delivery is a routine event that does not inherently increase the risk of infection unless complicated by prolonged labor, excessive blood loss, or retained placental fragments. While it is relevant to the patient’s history, it does not directly contribute to the current symptoms.
C. Breastfeeding 7 to 8 times a day for 10 minutes – While frequent nursing can sometimes contribute to sore nipples, it does not directly indicate an infection unless there are additional signs of inadequate emptying or poor latch.
D. Discharge hemoglobin of 9.2 g/dL (92 g/L) – A postpartum hemoglobin level lower than 11 g/dL suggests anemia, which can lead to fatigue, dizziness, and a weakened immune response. While anemia does not directly cause infection, it can contribute to the client’s symptoms of fatigue and dizziness and make it harder for the body to fight infections.
E. Current vital signs – The presence of fever (101.2°F/38.4°C) and tachycardia (105 beats/min) indicates a systemic inflammatory response, strongly suggesting an active infection. Given the combination of fever, chills, and breast tenderness, mastitis is a likely concern. Additionally, the foul-smelling lochia raises suspicion for endometritis.
F. Shopping yesterday for 5 hours – Being away from the baby for an extended period may have led to milk stasis, increasing the risk of mastitis. When milk is not regularly emptied, bacterial overgrowth can occur, leading to inflammation and infection, which aligns with the red, warm, firm area on the breast.
G. Foul-smelling lochia rubra – Lochia rubra persisting at two weeks postpartum, particularly with a foul odor, is a classic sign of endometritis, a postpartum uterine infection. Normal postpartum bleeding transitions from rubra to serosa, and foul-smelling discharge indicates bacterial overgrowth in the uterus, requiring prompt antibiotic treatment.

A. "The ointment will prevent a herpes infection." B. "The ointment will clear the infant's vision." C. "The ointment will dilate the pupil so the red reflex can be visualized." D. "The ointment will prevent eye infections."

Correct Answer is D

Explanation

A. "The ointment will prevent a herpes infection." Ophthalmic ointment, usually erythromycin, is given to prevent bacterial infections, particularly Neisseria gonorrhoeae and Chlamydia trachomatis. It does not prevent viral infections such as herpes simplex virus (HSV), which requires antiviral treatment if exposure is suspected.
B. "The ointment will clear the infant's vision." The ointment may temporarily blur the infant’s vision due to its thick consistency. Its purpose is not to enhance vision but to prevent neonatal conjunctivitis, which can cause blindness if left untreated.
C. "The ointment will dilate the pupil so the red reflex can be visualized." Pupil dilation is achieved using mydriatic eye drops, not antibiotic ointment. The red reflex is assessed during the newborn exam but is unrelated to the prophylactic eye medication.
D. "The ointment will prevent eye infections." Erythromycin ophthalmic ointment is routinely administered to newborns to prevent ophthalmia neonatorum, a serious eye infection caused by maternal gonorrhea or chlamydia exposure during delivery. This infection can lead to blindness if untreated, making prophylaxis essential.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.

Correct Answer is ["A","D","E","F","G"]

Explanation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?

Correct Answer is D

Explanation

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

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.

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?