Exhibits

The nurse determines the need to perform more of an assessment based on the client's symptoms.

Based on the new assessment findings, choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

Based on the assessment findings, the priority diagnosis suspected is
dropdown
This diagnosis places the client at risk of
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Mastitis: Mastitis is an infection of breast tissue that occurs when milk stasis leads to bacterial overgrowth, usually caused by Staphylococcus aureus. The client's firm, red, warm area on the breast, fever (101.2°F), chills, body aches, and fatigue all strongly indicate mastitis rather than other breast conditions.
Engorgement: Engorgement occurs when the breasts overfill with milk, leading to swelling and tenderness. However, engorgement typically affects both breasts, does not cause fever or flu-like symptoms, and resolves with regular breastfeeding or pumping.
Blocked milk duct: A clogged duct occurs when milk flow is obstructed, leading to a tender lump in the breast. While a blocked duct can progress to mastitis, it does not cause fever or systemic symptoms unless infection develops. The presence of fever and flu-like symptoms in this client suggests mastitis, not just a blocked duct.
Inflammatory breast cancer: This rare but aggressive form of breast cancer causes redness, swelling, and skin thickening, but it is not associated with fever or acute symptoms like mastitis. It does not develop suddenly but rather progresses over time, making mastitis the more likely diagnosis in this case.
Abscess: If mastitis is not treated promptly, it can lead to a breast abscess, a localized collection of pus requiring drainage. Signs of progression to an abscess include fluctuant swelling, worsening pain, and persistent fever despite antibiotic treatment.
Breastfeeding intolerance: Mastitis can cause temporary discomfort during breastfeeding, but it does not lead to true breastfeeding intolerance. In fact, continued breastfeeding helps resolve mastitis by improving milk drainage.
Nipple thrush: Nipple thrush (Candida infection) causes burning pain and white patches in the infant’s mouth but is not a complication of mastitis, which is bacterial, not fungal.
Postpartum haemorrhage: Postpartum hemorrhage is caused by uterine atony, retained placenta, or coagulation disorders, not mastitis. Mastitis is localized to the breast and does not affect uterine bleeding.

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Correct Answer is C

Explanation

A. Arched back. An arched back can be seen in conditions such as gastroesophageal reflux disease (GERD) or neurological disorders but is not a hallmark feature of the condition described. The presence of an olive-like mass and hunger despite vomiting suggests a different diagnosis.
B. Coffee-ground emesis. Coffee-ground emesis indicates the presence of digested blood, often seen in gastrointestinal bleeding. This is not a typical finding in infants with the described symptoms, which are more consistent with pyloric stenosis.
C. Projectile vomiting. The combination of dehydration, extreme hunger, and a palpable olive-like mass in the right upper abdomen is classic for hypertrophic pyloric stenosis. This condition causes progressive gastric outlet obstruction, leading to non-bilious, projectile vomiting after feeds. Vomiting occurs because food cannot pass through the thickened pyloric sphincter.
D. Frequent pauses. Frequent pauses during feeding may be observed in conditions such as respiratory distress or neuromuscular disorders, but they are not characteristic of pyloric stenosis. Infants with pyloric stenosis often appear eager to feed but vomit forcefully due to gastric outlet obstruction.

A. 1+ edema on her lower extremities. B. Fundal height of 30 cm. C. Weight gain of 2 pounds (0.91 kg). D. Fetal heart rate of 110 beats/minute.

Correct Answer is B

Explanation

A. 1+ edema on her lower extremities: Mild edema in the lower extremities is a common finding in the third trimester due to increased blood volume and venous stasis. It is not necessarily a concerning finding unless accompanied by signs of preeclampsia, such as hypertension or proteinuria.
B. Fundal height of 30 cm: At 34 weeks of gestation, the fundal height is typically expected to be within 2 cm of the gestational age (32–36 cm). A measurement of 30 cm is below the expected range and may indicate intrauterine growth restriction (IUGR) or oligohydramnios. This finding requires further evaluation by the healthcare provider.
C. Weight gain of 2 pounds (0.91 kg): A weight gain of approximately 1–2 pounds (0.45–0.91 kg) per week in the third trimester is within the normal range for pregnancy and does not require immediate intervention.
D. Fetal heart rate of 110 beats/minute: The normal fetal heart rate ranges between 110–160 beats per minute. While 110 bpm is at the lower end of normal, it is still within an acceptable range and does not necessarily indicate fetal distress. However, continued monitoring may be warranted if there are additional concerns.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Correct Answer is C

Explanation

A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?

Correct Answer is B

Explanation

Exhibits The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

Exhibits Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

Exhibits Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse knows that the mastitis in this scenario is most likely caused bydropdown, as evidenced bydropdown

Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.