A premenopausal client with uterine leiomyomas (fibroids) reports to the clinic nurse that her menstrual bleeding has increased in volume and duration. Which assessment should the nurse perform first?

Palpate the abdomen for uterine enlargement.

Observe the appearance of the bleeding on the client's pad.

Measure the client's vital signs.

Obtain a history of the exact length of each cycle.

Answer and Explanation

The Correct Answer is C

A. Palpate the abdomen for uterine enlargement: While abdominal palpation may reveal uterine enlargement, it is not the first priority. The nurse needs to assess the client’s current clinical status to determine if there is any immediate risk of complications like hemorrhage.
B. Observe the appearance of the bleeding on the client's pad: Observing the appearance of the bleeding is important for understanding the severity of the condition, but the nurse should first assess the client's vital signs to identify any signs of hemodynamic instability or shock.
C. Measure the client's vital signs: The most immediate assessment is to check the client’s vital signs, especially if the increased bleeding has caused any changes in her hemodynamic status. This step will help determine if the client is experiencing a serious complication such as hypovolemic shock.
D. Obtain a history of the exact length of each cycle: While obtaining a detailed history is helpful, it is not the first action. Vital signs should be checked first to ensure that the client is stable before gathering additional information.

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Correct Answer is C

Explanation

A. A primiparous adolescent living at home with her parents and significant other: While being a young, first-time mother may pose challenges, the support system of living with parents and a significant other may help mitigate psychological risks.

B. A multiparous female with a large family living in the community: A woman with multiple children and a support system in the community is less likely to experience significant psychological difficulties, as she may be more experienced and have more resources to draw from.

C. A primiparous woman who has recently immigrated to the U.S. with her spouse: This woman is at high risk for psychological difficulties, such as postpartum depression, due to potential isolation, lack of support, cultural differences, and challenges adjusting to a new environment without an extended support network.

D. A multiparous client who lives with her husband and his family members: While living with extended family can sometimes present stress, this client has a support system, including both her husband and family members, which may help reduce the risk of psychological difficulties.

A. The temperature taken at home is 99.0° F (37.2° C). B. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions. C. After a feeding, the nipple is creased. D. The infant continues to want to nurse all the time. E. Pain during feeding lasts for 10 of the 20 minutes of the feed. F. Pumping continues on the right side instead of breastfeeding on that side. G. The red area on her right breast has resolved. H. The feelings of fatigue continue, but there are no chills, achiness, or dizziness.

Correct Answer is ["A","B","G","H"]

Explanation

A. The temperature taken at home is 99.0° F (37.2° C): A normal temperature of 99.0°F indicates that the fever associated with mastitis has resolved from he initial 38.4° C, suggesting that the infection has been treated successfully.

B. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions:
Regular breastfeeding every 2-3 hours for 20 minutes helps ensure proper drainage of the breast, which is essential for preventing mastitis recurrence. Using various positions encourages effective drainage of milk from all areas of the breast.

C. After a feeding, the nipple is creased: A creased nipple suggests a potential problem with latching, which may cause pain or nipple damage. It is not indicative of mastitis resolution or proper breastfeeding management.

D. The infant continues to want to nurse all the time: Increased demand for nursing could indicate a growth spurt or an ineffective milk transfer, which doesn’t directly confirm that mastitis has been resolved. It shows breastfeeding might need to be reassessed.

E. Pain during feeding lasts for 10 of the 20 minutes of the feed: Persistent pain during feeding may indicate an improper latch, nipple trauma, or other issues, and is not a sign that mastitis has resolved. This requires evaluation of breastfeeding technique.

F. Pumping continues on the right side instead of breastfeeding on that side: Pumping rather than breastfeeding may suggest that the patient is avoiding breastfeeding from the affected breast due to pain or discomfort. It does not confirm that mastitis has been fully resolved.

G. The red area on her right breast has resolved: The red area in the breast, a key symptom of mastitis, resolving suggests that the infection has improved and that the inflammation is subsiding. This is a clear indicator that the mastitis has resolved.

H. The feelings of fatigue continue, but there are no chills, achiness, or dizziness: Fatigue can persist in the postpartum period, but the absence of chills, achiness, or dizziness indicates that the mastitis infection has resolved and the systemic symptoms are no longer present.

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A premenopausal client with uterine leiomyomas (fibroids) reports to the clinic nurse that her menstrual bleeding has increased in volume and duration. Which assessment should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

Correct Answer is C

Explanation

Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.

Correct Answer is ["A","B","G","H"]

Explanation

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