Nokea
A nurse is caring for a client who is 4 days postpartum following a cesarean birth
Nurses’ Notes
Today
0800
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender
with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without
erythema or drainage. Small amount of Lochia rubra noted.
0830
Provider notified of findings. Prescriptions received.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
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- A. Tell me what concerns you about the bedpan
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.
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- A. Keep visitors at least 6 feet(1.8 m) away from the client.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room.
- C. Wear an isolation gown when caring for the client.
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Correct Answer: B
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Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who has a prescription for compression stockings and did not receive them.
- B. A client who requests assistance in ambulating to the restroom.
- C. A client who ate 50% of their lunch tray.
- D. A client whose blood pressure is 88/52 mmHg.
Correct Answer: D
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