A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A white patch on a nipple

Red and painful area in one breast

Cracked and bleeding nipples

Swelling in both breasts

Answer and Explanation

The Correct Answer is B

A) A white patch on a nipple:

A white patch on the nipple may indicate a condition such as a milk bleb or a fungal infection like thrush, but it is not characteristic of mastitis. Mastitis typically presents with localized redness and pain in the affected breast, along with other systemic symptoms such as fever and flu-like symptoms.

B) Red and painful area in one breast:

This finding is indicative of mastitis. Mastitis is an inflammation of the breast tissue, often caused by bacterial infection, which presents with localized redness, warmth, swelling, and pain in one breast. The affected area may also feel tender or hard to the touch.

C) Cracked and bleeding nipples:

Cracked and bleeding nipples are common in breastfeeding mothers, but they are not specific signs of mastitis. However, they can increase the risk of mastitis if bacteria enter the breast tissue through the cracked skin. Proper breastfeeding techniques and nipple care can help prevent nipple damage and reduce the risk of mastitis.

D) Swelling in both breasts:

Swelling in both breasts may occur in the early postpartum period due to engorgement or increased milk production, but it is not a specific sign of mastitis. Mastitis typically presents with localized symptoms in one breast rather than both breasts simultaneously.

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Correct Answer is D

Explanation

A) Dry the infant off and cover the head:

While drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation, clearing the respiratory tract takes precedence immediately after delivery to ensure adequate breathing and oxygenation.

B) Stimulate the infant to cry:

While it is essential for newborns to establish effective respiratory efforts, stimulating the infant to cry is not the first action indicated after delivery. Crying may naturally occur as a response to the new environment, but it is not a reliable indicator of effective respiratory function.

C) Cut the umbilical cord:

Cutting the umbilical cord is typically done after the initial steps of newborn care, including clearing the respiratory tract. It is important to ensure that the infant is breathing adequately before attending to other tasks such as cord cutting.

D) Clear the respiratory tract:

Clearing the newborn's respiratory tract is the priority action immediately after delivery to ensure that the airway is clear of any amniotic fluid or debris, facilitating effective breathing and oxygenation. This may involve suctioning the mouth and nose as needed to remove any secretions and ensure unobstructed airflow.

A. Notify the client's provider. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Document the findings and continue to monitor the client.

Correct Answer is D

Explanation

A) Notify the client's provider:

There is no indication to notify the provider at this time. The presence of lochia rubra with small clots and a firm, midline fundus at the umbilicus indicates typical postpartum bleeding and uterine involution. This finding does not warrant immediate notification of the provider.

B) Encourage the client to empty her bladder:

Encouraging the client to empty her bladder is essential for promoting uterine contractions and preventing uterine atony. However, in this scenario, the fundus is already midline and firm, suggesting that bladder distension is not the cause of the excessive bleeding. While voiding may help, it is not the priority action.

C) Increase the frequency of fundal massage:

Increasing the frequency of fundal massage may not be necessary in this situation since the fundus is already midline and firm, indicating adequate uterine contractions. Fundal massage is typically performed if the fundus is boggy or if there is excessive bleeding.

D) Document the findings and continue to monitor the client:

This is the correct action. Documenting the assessment findings, including the amount and character of lochia, presence of clots, and fundal height, is essential for ongoing monitoring and evaluation of the client's postpartum recovery. Continuing to monitor the client allows the nurse to detect any changes in condition that may require further intervention.

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A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?