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
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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 D

Explanation

A. Notify the operating room team. While an emergency cesarean delivery may be necessary, the immediate priority is relieving pressure on the prolapsed umbilical cord to prevent fetal hypoxia. Positioning the client first helps improve fetal oxygenation while preparing for further interventions.
B. Administer a fluid bolus of 500 mL. IV fluids can help maintain maternal blood pressure and improve placental perfusion, but they do not directly relieve cord compression. Repositioning the client to reduce cord compression takes priority over fluid administration.
C. Administer oxygen via face mask. Oxygen supplementation may help improve fetal oxygenation, but it does not address the underlying issue of cord compression. The first intervention should be to reposition the client to relieve pressure on the cord before providing supplemental oxygen.
D. Place the client in Trendelenburg. A prolapsed umbilical cord is a medical emergency requiring immediate action to prevent fetal hypoxia. The Trendelenburg or knee-chest position uses gravity to shift the fetus away from the cord, reducing compression. The nurse should also manually elevate the presenting part if necessary and prepare for an emergency cesarean delivery.

A. Establish the frequency of headaches. B. Ask about a history of delivering large babies. C. Examine the client for pedal edema. D. Collect a urine sample to screen for protein.

Correct Answer is D

Explanation

A. Establish the frequency of headaches. While assessing headache history is important, an excruciating headache in a pregnant client with elevated blood pressure is a concerning sign of possible preeclampsia. Immediate evaluation for organ involvement, such as proteinuria, is more critical than determining headache patterns.
B. Ask about a history of delivering large babies. A history of macrosomia is more relevant for assessing gestational diabetes rather than hypertensive disorders. In this case, the priority is identifying potential complications of preeclampsia, which requires urine protein testing.
C. Examine the client for pedal edema. Although edema can be a sign of preeclampsia, it is also common in normal pregnancy. Generalized edema, particularly in the face and hands, may be more concerning, but the presence or absence of edema does not confirm or rule out preeclampsia.
D. Collect a urine sample to screen for protein. Proteinuria is a key diagnostic criterion for preeclampsia, along with hypertension and systemic symptoms such as severe headache. A urine dipstick or 24-hour urine collection helps determine if the client has preeclampsia, which requires urgent management to prevent complications like eclampsia or placental abruption.

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Naxlex Comprehensive Predictor Exams

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

Correct Answer is D

Explanation

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is D

Explanation

Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?

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?

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?

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?