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A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Recommend the client avoid wearing a nursing bra until symptoms resolve.
- B. Suggest the client apply warm compresses to the affected breast.
- C. Encourage the client to limit oral fluid intake to decrease milk production.
- D. Tell the client to apply hydrocortisone ointment to the affected area.
Correct Answer: B
Rationale: Applying warm compresses relieves pain and inflammation in mastitis, promoting circulation and healing.
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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. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
- A. Image showing toes fanning out when the sole is stroked.
- B. Image showing the newborn grasping a finger when the palm is touched.
- C. Image showing the newborn turning the head when the cheek is stroked.
- D. Image showing the newborn making stepping movements when held upright.
Correct Answer: A
Rationale: The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex, a normal newborn response indicating immature nervous system development.
Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Take sips of milk between meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Lie in a left side-lying position for 30 minutes after meals.
Correct Answer: A
Rationale: Sips of milk neutralize stomach acid, providing heartburn relief, a practical solution for pregnant clients.
History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.