The nurse is reviewing discharge instructions with the postpartum client who had a cesarean section 4 days ago and will include which of the following warning signs to report once she is home?
Red, tender area on breast.
Temperature of 100.8°F.
Burning on urination.
Increased lochia rubra.
Correct Answer : A,B,C,D
Choice A rationale
A red, tender area on the breast could indicate mastitis, an infection of the breast tissue. This requires prompt medical attention to prevent complications and provide appropriate treatment, often involving antibiotics.
Choice B rationale
A temperature of 100.8°F is considered a fever and could indicate an infection. Postpartum clients are at risk of infections, including endometritis, and should report any fever to their healthcare provider for further evaluation.
Choice C rationale
Burning on urination could indicate a urinary tract infection (UTI). UTIs are common postpartum due to catheter use and trauma during delivery. This symptom should be reported for evaluation and treatment if necessary.
Choice D rationale
Increased lochia rubra can indicate postpartum hemorrhage or retained placental fragments. Any significant change in bleeding pattern should be reported to ensure timely management and prevent serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Prolactin is the hormone responsible for the production of breast milk. It is produced by the anterior pituitary gland and stimulates the mammary glands to produce milk. Prolactin levels increase during pregnancy and breastfeeding to ensure a sufficient milk supply.
Choice B rationale: Progesterone plays a role in preparing the breast tissue for lactation during pregnancy, but it does not directly stimulate milk production.
Choice C rationale: Hindmilk is the milk produced later in a feeding session, which is richer in fat and calories. It is not a hormone and does not stimulate milk production.
Choice D rationale: Foremilk is the initial milk released during breastfeeding, which is higher in water content. It is also not a hormone and does not stimulate milk production.
Correct Answer is F
Explanation
Choice A rationale
Stools are a normal occurrence in newborns and are not typically associated with significant complications. The frequency and consistency can vary, but abnormal stools would not explain the given vital signs.
Choice B rationale
Temperature control is vital in newborns, but the given temperature is slightly low and alone does not indicate a specific complication without additional context such as infection or environment.
Choice C rationale
Feeding difficulties can occur in newborns, but they would typically present with symptoms related to weight and growth rather than the specific vital signs provided.
Choice D rationale
Extremities’ conditions, such as cyanosis or poor circulation, could indicate complications, but the given vital signs are not directly indicative of extremity problems.
Choice E rationale
Hypoglycemia in newborns can present with signs like jitteriness or lethargy, but it does not directly correlate with the provided vital signs without additional glucose measurements.
Choice F rationale
Neonatal Abstinence Syndrome (NAS) includes symptoms such as high heart rate, respiratory rate, and temperature instability, which align with the newborn's vital signs.
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