Nokea
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
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History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which are the 3 most likely reasons that the infant is crying?
- A. Hunger
- B. Opioid withdrawal
- C. Hemorrhage
- D. Separation anxiety
- E. Pain
- F. Hypovolemia
- G. Hypoxia
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.
A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Establish the frequency of headaches.
- B. Ask about a history of delivering large babies.
- C. Examine the client for pedal edema.
- D. Collect a urine sample to screen for protein.
Correct Answer: D
Rationale: Severe headache and hypertension suggest preeclampsia. Screening for proteinuria is critical to confirm the diagnosis and guide urgent management.
The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer?
- A. Hepatitis B immunoglobulin.
- B. Rubella vaccination.
- C. Blood transfusion.
- D. Penicillin G potassium.
Correct Answer: B
Rationale: The client's rubella non-immune status requires postpartum vaccination to prevent future congenital defects. Normal hemoglobin/hematocrit, negative hepatitis B, and post-delivery GBS status do not warrant other interventions.
A client who is in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
- A. Notify the operating room team.
- B. Administer a fluid bolus of 500 mL.
- C. Administer oxygen via face mask.
- D. Place the client in Trendelenburg.
Correct Answer: D
Rationale: Trendelenburg positioning relieves umbilical cord compression, preventing fetal hypoxia in this emergency.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Administer antibiotics for 7 to 10 days.
- C. Give zidovudine 6 to 12 hours after birth.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: C
Rationale: Zidovudine within 6-12 hours reduces perinatal HIV transmission risk in newborns of HIV-positive mothers.