The nurse takes a phone call from a client at two weeks postpartum. The client states, "My left breast hurts." What other question will the nurse ask her to determine if it is mastitis?
"Do you have an inverted nipple on the affected breast?"
"Do you have breast milk in the affected breast?"
"Is there a bruised area on the affected breast?"
"Is there a hardening of an area in the affected breast?"
The Correct Answer is D
A. An inverted nipple is not indicative of mastitis.
B. Presence of breast milk is expected postpartum and does not specifically indicate mastitis.
C. A bruised area is not a common sign of mastitis.
D. Mastitis often presents with localized pain, redness, swelling, and a hardening of the affected area of the breast. Asking about the presence of a hardening will help assess for mastitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Client 4, who delivered 8 hours ago, having a fundus at the umbilicus is within the expected range for a client at this stage postpartum.
B. Client 2, two days postpartum with a fundus 2 cm above the umbilicus, is suggestive of uterine subinvolution, as the fundus should be descending, not rising, after delivery.
C. Client 1, three days postpartum with a fundus 3 cm below the umbilicus, is within the expected range for the postpartum period.
D. Client 3, one day postpartum with a fundus 1 cm below the umbilicus, is within the expected range for the postpartum period.
Correct Answer is D
Explanation
A. Initiating oxytocin infusion is not the priority before the insertion of dinoprostone. Fetal monitoring is a more immediate concern.
B. Ensuring the client eats a light meal and drinks fluids is important for general well-being but is not the priority before dinoprostone insertion.
C. Placing the catheter and sterile saline at the bedside may be done later but is not the priority before insertion.
D. Continuous monitoring of the fetal heart rate and uterine activity is essential to assess the response to cervical ripening agents, as they can cause uterine hyperstimulation and fetal distress.
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