The nurse educates the breastfeeding client diagnosed with m...

The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? Select all that apply.

A. “Incorrect latch of my baby can lead to mastitis.”
B. “I should perform hand hygiene before I breastfeed.”
C. “I should rinse my baby’s mouth before I let her latch.”
D. “A tight underwire bra has support that prevents mastitis.”
E. “I should allow my nipples to air-dry after breastfeeding.”

Correct Answer: A,B,E

Rationale: Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens. Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion. While the infant’s nose and throat are sources of pathogenic organisms that might cause mastitis, washing the infant’s mouth would be difficult and would not provide adequate protection for the mother. Wearing a tight bra, especially with an underwire, may restrict milk ducts, providing milk stasis and a medium for pathogenic growth. Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment.

The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.

A. “Return for a blood transfusion if bleeding continues to be dark red.”
B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
C. “I can make a referral to a pregnancy loss support group if you like.”
D. “You need to use contraceptives to avoid getting pregnant for one year.”
E. “Someone should remain with you at home for the first 12 to 24 hours.”

Correct Answer: C,E

Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.

The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.

A. Auscultate maternal heart tones.
B. Measure the height of the fundus.
C. Measure the client’s abdominal girth.
D. Complete a third-trimester ultrasound.
E. Auscultate the fetal heart tones (FHT).

Correct Answer: B,E

Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.

The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.

A. Before the first missed menstrual period
B. During the first trimester
C. During the second trimester
D. During the third trimester
E. One week following delivery

Correct Answer: B,D

Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.

Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.

A. The client who is having symptoms of preterm labor
B. The women who had a neonatal death 1 year ago
C. All pregnant women coming to the clinic for care
D. The women who had a spontaneous abortion 1 week ago
E. The women who had an abortion for an unwanted pregnancy

Correct Answer: A,C

Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.

The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?

A. Encourage the client to push.
B. Notify the obstetrician or midwife.
C. Help the client to the bathroom.
D. Complete another vaginal exam.

Correct Answer: D

Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.