Nokea
A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority?
- A. Ineffective breastfeeding.
- B. Infection.
- C. Ineffective individual coping.
- D. Pain.
Correct Answer: B
Rationale: Infection is the primary concern.
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A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
- A. Abdominal striae.
- B. Oliguria.
- C. Omphalocele.
- D. Absent bowel sounds.
Correct Answer: D
Rationale: Absence of bowel sounds suggests ileus.
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
- A. 16-hour-old baby who has yet to pass meconium.
- B. 16-hour-old baby whose blood glucose is 50 mg/dL.
- C. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
- D. 2-day-old baby who is excreting a milky discharge from both nipples.
Correct Answer: C
Rationale: Irregular breathing at 70 breaths per minute could indicate respiratory distress and requires further evaluation.
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
- A. Moderate lochia flow.
- B. Decreased pain level.
- C. Stable blood pressure.
- D. Fundus above the umbilicus.
Correct Answer: A
Rationale: Improved lochia flow indicates resolution of atony.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
- A. Endometrial ischemia.
- B. Postpartum hemorrhage.
- C. Prolapsed uterus.
- D. Vaginal hematoma.
Correct Answer: B
Rationale: Abnormal placentas increase hemorrhage risk.