Nokea
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.
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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.
Select the findings that will help the nurse determine what is causing the client's symptoms.
- A. Rupture of membranes for 16 hours
- B. Normal spontaneous vaginal birth
- C. Breastfeeding 7 to 8 times a day for 10 minutes
- D. Discharge hemoglobin of 9.2 g/dL (92 g/L)
- E. Current vital signs
- F. Shopping yesterday for 5 hours
- G. Foul-smelling lochia rubra
Correct Answer: A,D,E,F,G
Rationale: Prolonged rupture of membranes, low hemoglobin, fever, tachycardia, prolonged shopping, and foul-smelling lochia suggest postpartum infection risks like endometritis or mastitis. These findings indicate systemic inflammation, anemia, and potential milk stasis.
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 description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.
- A. After a feeding, the nipple is creased.
- B. The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
- C. The infant continues to want to nurse all the time.
- D. The temperature taken at home is 99.0° F (37.2° C).
- E. Pain during feeding lasts for 10 of the 20 minutes of the feed.
- F. Pumping continues on the right side instead of breastfeeding on that side.
- G. The red area on her right breast has resolved.
Correct Answer: D,G
Rationale: Normal temperature, resolved redness, and effective breastfeeding every 2-3 hours in varied positions confirm mastitis resolution. Creased nipples, persistent pain, or exclusive pumping suggest ongoing issues.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood cultures.
- B. Administer penicillin.
- C. Prepare for a cesarean section.
- D. Cover the lesion with a dressing.
Correct Answer: C
Rationale: Cesarean section prevents neonatal herpes transmission during delivery with active lesions.
The nurse is caring for a child with a unilateral long-leg cast applied for the correction of club foot. Which action is most important for the nurse to perform?
- A. Palpate femoral pulses.
- B. Compare temperature of both legs.
- C. Monitor capillary refill of the toes.
- D. Examine for spontaneous movement.
Correct Answer: C
Rationale: Monitoring capillary refill ensures adequate circulation in the casted limb, detecting complications like compartment syndrome.
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.