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 C

Explanation

C) Cephalhematoma:

A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.

A) Caput succedaneum:

Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

B) Pilonidal dimple:

A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

D) Molding:

Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.

A. Orthostatic hypotension B. Heart rate 110/min C. Fundus palpable at the umbilicus D. Urine output of 3,000 mL in 12 hr

Correct Answer is B

Explanation

A) Orthostatic hypotension:

Orthostatic hypotension, although it can occur postpartum due to changes in fluid volume and hormone levels, is not typically an immediate sign of a postpartum complication. It may occur as the body adjusts to changes after delivery but is not necessarily indicative of a complication on its own.

B) Heart rate 110/min:

A heart rate of 110/min is elevated and may indicate a postpartum complication such as hemorrhage, infection, or other cardiovascular issues. An elevated heart rate can be a sign of physiological stress or inadequate perfusion, requiring further assessment and intervention by the nurse.

C) Fundus palpable at the umbilicus:

A fundus palpable at the umbilicus is a normal finding for a client who is 12 hr postpartum. Immediately after delivery, the fundus is typically firm and located at or just below the level of the umbilicus. Over time, it should descend and become firmer as the uterus involutes.

D) Urine output of 3,000 mL in 12 hr:

An unusually high urine output of 3,000 mL in 12 hr may indicate excessive fluid loss, which could be a sign of postpartum hemorrhage. While it is essential for postpartum clients to void frequently to prevent urinary retention, such a high output warrants further investigation by the nurse to rule out complications.

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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

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Explanation

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Correct Answer is B

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