A nurse is caring for a postpartum client in an outpatient setting.
Complete the following sentence by using the lists of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Mastitis is a breast infection that can occur in breastfeeding women. It causes inflammation, pain, redness, and sometimes fever and pus in the affected breast. One of the risk factors for mastitis is nipple trauma, such as cracks or fissures, that can allow bacteria to enter the breast tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","G","H"]
Explanation
A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.
B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.
Correct Answer is C
Explanation
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
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