How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assisting with the care of a client who is postpartum.

Exhibits

The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

A.

Purulent nipple discharge

B.

Moderate lochia rubra

C.

Client reports decreased level of pain

D.

WBC count 35,000/mm3

E.

Temperature 38.4° C (101.1° F)

F.

Hgb 12 g/dL.

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A"}}

  • Purulent nipple discharge. The presence of purulent (pus-like) discharge from the nipple suggests a worsening breast infection, possibly progressing to an abscess. This requires further evaluation and potential drainage or antibiotic therapy adjustment.
  • Moderate lochia rubra. Lochia rubra is the expected vaginal discharge in the first few days postpartum, reflecting normal uterine healing. It is not related to mastitis, so this finding does not indicate improvement or worsening of the breast infection.
  • Client reports decreased level of pain. A decrease in pain suggests that the inflammation and infection in the breast are responding to treatment, indicating recovery from mastitis.
  • WBC count 35,000/mm³. The client’s WBC count has increased from 28,000 to 35,000/mm³, which suggests that the infection is not resolving and may be worsening. This could indicate persistent or spreading mastitis, requiring reassessment of treatment.
  • Temperature 38.4°C (101.1°F). The temperature has decreased from 38.94°C (102.1°F) to 38.4°C (101.1°F), indicating a positive response to treatment and a possible reduction in infection severity.
  • Hgb 12 g/dL. The client’s hemoglobin level has slightly decreased from 13 g/dL to 12 g/dL, but this is within the normal range and is not directly related to mastitis. Mild postpartum hemoglobin changes are expected due to blood loss during delivery.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

A. Administer NSAIDs every 4 to 6 hr. NSAIDs help manage postpartum pain and inflammation but do not prevent thrombophlebitis. While pain control may encourage mobility, NSAIDs alone do not address the underlying risk of blood clot formation.
B. Apply warm, moist packs to the client's lower legs. Warm compresses may be used for comfort if a clot is already present, but they are not a preventive measure. Applying heat without medical indication may increase the risk of complications if a deep vein thrombosis (DVT) is present.
C. Apply elastic stockings before the client gets out of bed. Compression stockings help reduce venous stasis, but they should be used alongside movement rather than as a sole prevention method. They are most effective when combined with early ambulation and proper hydration.
D. Have the client ambulate as often as possible. Early and frequent ambulation is the most effective way to prevent thrombophlebitis after a cesarean birth. Walking promotes circulation, reduces venous stasis, and lowers the risk of blood clot formation, which is increased due to pregnancy-related hypercoagulability.

Correct Answer is B

Explanation

A. 1 cup sweet white corn. Corn contains minimal amounts of calcium, providing only about 2 mg per cup. While it is a source of fiber and carbohydrates, it does not significantly contribute to daily calcium needs, which are essential for fetal bone and teeth development during pregnancy.
B. 1 cup kale. Kale is a rich plant-based source of calcium, providing approximately 90 mg per cup. It is also high in vitamin K, which supports bone health. For individuals who do not consume dairy, dark leafy greens like kale, spinach, and collard greens are excellent alternatives for meeting calcium requirements.
C. 1 baked potato. A baked potato contains about 20 mg of calcium, which is relatively low. While potatoes provide potassium and vitamin C, they are not a significant source of calcium and would not be the best recommendation for a client avoiding dairy.
D. 1 large banana. Bananas provide about 5-10 mg of calcium per serving, making them a poor source of dietary calcium. They are more beneficial for their potassium content, which helps regulate fluid balance and muscle function but does not significantly contribute to calcium intake.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register