Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?
A. A white patch on a nipple
A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples
Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts
Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. Red and painful area in one breast
A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A. A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
Similar Questions
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?
A. "I'll feed my baby every 2 hours."
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
B. "I'll apply cold compresses 20 minutes before each feeding."
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
C. "I'll try drinking an herbal tea to reduce the engorgement."
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
D. "I'll let my baby drain one breast at each feeding."
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding toensure adequate milk removal from both breasts.
Full Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
A. Fundus palpable to right of midline
The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on perineal pad
Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions
Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst
Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.
Full Explanation
A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.
A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
A. 110/min
A respiratory rate of 110/min is elevated for a newborn and may indicate respiratory distress.
B. 48/min
A respiratory rate of 48/min is within the normal range too low for a newborn and may indicate respiratory depression or other respiratory problems.
C. 22/min
A respiratory rate of 22/min is too low for a newborn and may indicate respiratory depression or other respiratory problems.
D. 100/min
A respiratory rate of 100/min is within the expected reference range for a newborn. Normal respiratory rates for newborns typically range from 30 to 60 breaths per minute, with somevariability.
Full Explanation
a. 110/min - This respiratory rate is higher than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.
b. 48/min - This respiratory rate falls within the expected reference range for a newborn, which is typically between 30 to 60 breaths per minute.
c. 22/min - This respiratory rate is lower than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.
d. 100/min - While this respiratory rate is within the expected range, it's at the upper end of the range for a newborn. Typically, newborns have respiratory rates between 30 to 60 breaths per minute, so a rate of 100/min may be considered slightly elevated.