Nokea
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions.
- A. Pulse of 105 beats/minute - Both mastitis and endometritis
- B. Feeling chilled, achy, and fatigued - Both mastitis and endometritis
- C. Baby fed pumped breast milk - Mastitis
- D. Pain rating of 4 on a 0 to 10 scale - Mastitis
- E. Foul-smelling lochia rubra at 2 weeks postpartum - Endometritis
- F. Temperature of 101.2° F (38.4°C) - Both mastitis and endometritis
Correct Answer: B,D
Rationale: Tachycardia, chills, aches, fatigue, and fever are systemic signs of infection in both mastitis and endometritis. Feeding pumped milk and localized breast pain suggest mastitis due to milk stasis. Foul-smelling lochia is specific to endometritis, indicating uterine infection.
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The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
- A. Folic acid.
- B. Iron.
- C. Vitamin D.
- D. Calcium.
Correct Answer: A
Rationale: Folic acid (400-800 mcg daily) prevents neural tube defects like anencephaly by supporting neural tube closure.
A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
- A. Complete the assessment while allowing the child to cry.
- B. Explain to the child the reasons an examination is needed.
- C. Talk to the mother and gradually focus on the child's toy.
- D. Request extra staff to help with the nursing assessments.
Correct Answer: C
Rationale: Engaging the mother and using the child's toy as a distraction builds trust, reducing anxiety and encouraging cooperation.
Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?
- A. Administer antipyretic medication on a continuous basis.
- B. Continue strict monitoring of daily wet diapers for 1 week.
- C. Have the antibiotic trough level drawn within 3 days.
- D. Monitor the infant for response to auditory stimuli.
Correct Answer: D
Rationale: Monitoring auditory responses detects hearing loss, a common meningitis complication, requiring follow-up screening.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
Which education by the nurse will help resolve the issue for the client? Select all that apply.
- A. Wear an underwire bra around the clock.
- B. Apply warm compresses to affected area before feeding.
- C. Pump breasts if feeding will be missed, due to absence from the infant.
- D. Pump breastmilk and feed it to infant instead of nursing.
- E. Finish antibiotics even if symptoms improve.
- F. Maintain activity due to the risk of blood clots with extra rest.
- G. Wash hands before handling the breast.
Correct Answer: B,C,E,G
Rationale: Warm compresses, pumping to prevent milk stasis, completing antibiotics, hand hygiene, starting on the unaffected side, and varying positions promote milk flow, reduce infection risk, and ensure effective breastfeeding. Underwire bras and avoiding rest are not recommended.
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
- A. Arched back.
- B. Coffee-ground emesis.
- C. Projectile vomiting.
- D. Frequent pauses.
Correct Answer: C
Rationale: Projectile vomiting is characteristic of pyloric stenosis, indicated by the olive-like mass, hunger, and dehydration.