Nokea
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Limit the client's daily fluid intake
- B. Encourage the client to wear a bra that is loose fitting
- C. Encourage the client to continue to breastfeed.
- D. Prepare the client for an abdominal sonogram
Correct Answer: C
Rationale: Continued breastfeeding prevents milk stasis and reduces the risk of abscess formation in mastitis.
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A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. Wash your nipples with soap and water daily.
- B. You should use a breast pump if you plan to return to work.
- C. Cover your breasts immediately after feedings.
- D. Wear an underwire bra between feedings.
Correct Answer: B
Rationale: Using a breast pump prevents milk stasis, a major risk factor for mastitis, by ensuring regular milk expression when away from the baby.
A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia.
Which of the following medications should the nurse plan to administer?
- A. Amoxicillin
- B. Acyclovir
- C. Metronidazole
- D. Tetracycline
Correct Answer: A
Rationale: Amoxicillin is safe and effective for treating chlamydia during pregnancy, posing no known fetal risks.
History and Physical: Repeat caesarean birth 3 days ago, mastitis. Vital Signs: BP 130/84 mm Hg, HR 106/min, RR 20/min, Temp 38.94°C. Assessment: WBC 28,000/mm3, Hgb 13 g/dL, Hct 37%, redness/warmth in left breast, cracked nipples, body aches, chills, headache, breast tenderness.
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?
- A. Purulent nipple discharge: Sign of potential worsening condition
- B. Moderate lochia rubra: Unrelated to diagnosis
- C. Client reports decreased level of pain: Sign of potential improvement
- D. WBC count 35,000/mm3: Sign of potential worsening condition
- E. Temperature 38.4° C (101.1° F): Sign of potential improvement
- F. Hgb 12 g/dL: Unrelated to diagnosis
Correct Answer: A,C,D,E
Rationale: Purulent discharge and increased WBC suggest worsening mastitis, while decreased pain and lower temperature indicate improvement. Lochia and hemoglobin are unrelated to mastitis.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Give a bolus of lactated Ringer's
- B. Assist the client to empty her bladder.
- C. Place the client in knee chest position.
- D. Administer methylergonovine IM.
Correct Answer: A
Rationale: A bolus of lactated Ringer's increases intravascular volume, stabilizing blood pressure caused by epidural-induced vasodilation.