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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Return of the uterus to prepregnancy size. While oxytocin helps contract the uterus, the complete process of involution (uterus returning to prepregnancy size) takes about 6 weeks postpartum. Oxytocin primarily aids in immediate postpartum contraction to reduce bleeding.
B. Expulsion of the placenta. Oxytocin is typically administered after placental delivery to prevent postpartum hemorrhage. If the placenta does not expel naturally, manual removal may be needed. Oxytocin is more effective in promoting uterine tone rather than actively expelling the placenta.
C. Activation of the let-down reflex. Oxytocin plays a role in milk ejection during breastfeeding, but when administered intravenously postpartum, its primary purpose is to stimulate uterine contractions. Natural oxytocin release from breastfeeding supports the let-down reflex, but this is not the main goal of IV oxytocin administration.
D. Stimulation of uterine contractions. IV oxytocin is given postpartum to promote uterine contractions, which help reduce postpartum bleeding by compressing uterine blood vessels. This action is critical in preventing postpartum hemorrhage and ensuring uterine firmness.

A. Variability of fetal heart rate. B. Station of presenting part. C. Level of pain sensation. D. Maternal blood pressure.

Correct Answer is D

Explanation

A. Variability of fetal heart rate. While fetal heart rate (FHR) variability is important, it is not the most immediate concern after epidural administration. Maternal hypotension can reduce placental perfusion, leading to fetal distress, but the priority is detecting and managing hypotension before significant FHR changes occur.
B. Station of presenting part. The fetal station indicates the descent of the presenting part in the birth canal but is unrelated to epidural anesthesia. Although epidurals can impact labor progression, station assessment is not the most critical immediate concern after administration.
C. Level of pain sensation. Assessing pain relief is necessary, but it is secondary to monitoring for maternal hypotension, which can cause serious complications for both mother and fetus. Pain control should be evaluated after ensuring hemodynamic stability.
D. Maternal blood pressure. Epidural anesthesia can cause vasodilation and sudden hypotension due to sympathetic blockade, leading to decreased placental perfusion and fetal distress. Frequent blood pressure monitoring is essential to detect hypotension early and intervene with IV fluids, repositioning, or vasopressors if needed.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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.