Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is 4 days postpartum following a cesarean birth

Exhibits

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process

A.

Painful, tender breast

B.

Temperature

C.

Chills

D.

Foul-smelling lochia

Answer and Explanation

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

Mastitis: A, B, C

Endometritis: B, C, D

Rationale:
A.    This finding is consistent with mastitis. Mastitis is characterized by inflammation of the breast tissue, often presenting with pain, tenderness, warmth, and redness in the affected breast.
B.    This finding can be indicative of both mastitis and endometritis. A fever, as indicated by an elevated temperature (38.8°C or 101.9°F), is a common symptom of both mastitis and endometritis. It suggests an inflammatory response or infection in the body.
C.    This finding is also consistent with both mastitis and endometritis. Chills often accompany fever and can be a sign of systemic infection or inflammation.
D.    This finding is more indicative of endometritis. Endometritis involves infection or inflammation of the uterine lining, which can result in foul-smelling lochia. Foul- smelling lochia may indicate the presence of infection within the uterus.
 


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 B

Explanation

A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.

Correct Answer is C

Explanation

A. Both fontanels show molding. Molding is seen immediately after birth due to the passage through the birth canal and should not be present at 8 months.
B. The posterior fontanel is open. The posterior fontanel usually closes by 2 to 3 months of age.
C. For an 8-month-old infant, it is normal for the anterior fontanel to still be open. It typically closes between 12 to 18 months of age.
D. Both fontanels are the same size. The anterior and posterior fontanels are naturally different sizes; the anterior is larger.

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