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.
After a feeding, the nipple is creased.
The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
The infant continues to want to nurse all the time.
The temperature taken at home is 99.0° F (37.2° C).
Pain during feeding lasts for 10 of the 20 minutes of the feed.
Pumping continues on the right side instead of breastfeeding on that side.
The red area on her right breast has resolved.
The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions.
Correct Answer : D,G,H
A. After a feeding, the nipple is creased. A creased nipple suggests a poor latch, which can lead to ineffective milk removal and increase the risk of recurrent mastitis. A proper latch should be deep, with the baby covering a large portion of the areola, ensuring effective drainage of the breast.
B. The feelings of fatigue continue, but there are no chills, achiness, or dizziness. While the absence of chills, achiness, and dizziness indicates improvement, persistent fatigue may suggest anemia, inadequate hydration, or continued recovery from infection. Fatigue alone does not confirm complete resolution of mastitis.
C. The infant continues to want to nurse all the time. Cluster feeding can be normal during growth spurts, but persistent frequent feeding beyond 2–3 hours may indicate poor milk transfer, low supply, or ineffective latch. Mastitis resolution should result in more effective milk drainage and a more predictable feeding pattern.
D. The temperature taken at home is 99.0° F (37.2° C). A normal temperature suggests that the infection and systemic inflammation have resolved. Mastitis is characterized by fever, so its absence indicates improvement.
E. Pain during feeding lasts for 10 of the 20 minutes of the feed. Persistent pain, especially for half the feeding duration, may indicate ongoing inflammation, nipple trauma, or unresolved infection. Resolution of mastitis should lead to pain-free or minimal discomfort during feeding.
F. Pumping continues on the right side instead of breastfeeding on that side. If the affected breast is still too painful for direct nursing, this suggests ongoing inflammation or poor resolution of mastitis. Ideally, the mother should be able to comfortably breastfeed from both breasts.
G. The red area on her right breast has resolved. The disappearance of redness, swelling, and warmth indicates resolution of localized inflammation and infection, confirming improvement in mastitis.
H. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions. Effective breastfeeding frequency and positioning ensure proper milk drainage, reducing the risk of recurrence. Mastitis resolution should allow the mother to comfortably breastfeed at regular intervals with different holds to promote complete emptying of all milk ducts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid any smoking inside the house. Exposure to secondhand smoke increases the risk of recurrent otitis media by irritating the respiratory tract and impairing mucociliary clearance. Reducing or eliminating smoke exposure is an essential preventive measure to lower inflammation and decrease bacterial colonization in the middle ear.
B. Give infant the full course of antibiotics. Completing the full course of prescribed antibiotics ensures that the infection is fully treated, preventing bacterial resistance and reducing the likelihood of recurrent or persistent infections. Stopping antibiotics prematurely can lead to incomplete eradication of the bacteria and increase the risk of future infections.
C. Schedule visit for pneumococcal vaccine. The pneumococcal vaccine protects against Streptococcus pneumoniae, one of the leading causes of otitis media. Ensuring that the infant is up to date with routine vaccinations, including the pneumococcal and Haemophilus influenzae type B (Hib) vaccines, can significantly reduce the risk of recurrent infections.
D. Instill benzocaine otic drops regularly. Benzocaine otic drops provide temporary pain relief but do not prevent or treat infections. Using them regularly without medical guidance may mask symptoms of worsening infection, delay appropriate treatment, or cause local irritation. Pain management should be used only as needed and in conjunction with appropriate medical interventions.
Correct Answer is ["A","B"]
Explanation
A. FLACC Postoperative Pain Scale: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is commonly used for infants and young children who cannot verbally report their pain. It assesses behavioral cues such as facial expressions, leg movement, activity level, crying, and ability to be consoled, making it appropriate for this 4-month-old infant.
B. Riley Infant Pain Scale: This scale is specifically designed for infants under 1 year of age. It evaluates facial expression, sleep patterns, movements, crying, and verbal cues to determine the level of discomfort. Since this infant is postoperative and unable to self-report pain, this scale is a useful tool.
C. Poker Chip Tool: This tool is used for older children, typically 4 years and above, who can understand the concept of counting and associating poker chips with pain intensity. It is not appropriate for a 4-month-old infant who lacks the cognitive ability to use symbolic representation.
D. Visual Analog Scale: This scale requires the client to mark pain intensity on a continuous line, making it appropriate only for older children (around 7 years and older) who understand abstract concepts. A 4-month-old infant cannot comprehend or use this scale.
E. Numeric: The numeric pain scale (0–10) is used for older children and adults who can assign a number to their pain. Infants and young children cannot use this scale, making it inappropriate for this client.
F. FACES: The Wong-Baker FACES Pain Rating Scale is designed for children 3 years and older who can recognize and correlate facial expressions with pain levels. A 4-month-old does not have the cognitive ability to use this scale reliably.
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