Question

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.)

Answer 1

Correct Answers:

Breast tenderness
Warmth in the breast
An area of redness on the breast often resembling the shape of a pie wedge
Fever and flu-like symptoms

Rationale :

Breast tenderness

🌸 Mastitis commonly causes breast tenderness and pain because the breast tissue becomes inflamed and infected.

🌸 The affected area is often sore to touch and may become increasingly uncomfortable during breastfeeding.

🌸 This tenderness usually occurs along with localized swelling and firmness in the involved breast.

🌸 Breast pain is one of the most common early symptoms that prompts the mother to seek care.

🌸 For that reason, breast tenderness is an expected finding in mastitis.

Warmth in the breast

🌸 The involved breast area often feels warm because inflammation increases blood flow to the infected tissue.

🌸 This localized warmth is a classic sign of an inflammatory or infectious process.

🌸 The warmth is usually limited to the affected portion rather than the entire breast.

🌸 It often appears together with redness, pain, and swelling.

🌸 That makes breast warmth an expected symptom of mastitis.

An area of redness on the breast often resembling the shape of a pie wedge

🌸 A wedge-shaped area of redness is a very classic description of mastitis.

🌸 The redness usually reflects inflammation in one section of the breast, often where milk stasis and infection have developed.

🌸 This pattern helps distinguish mastitis from more generalized breast discomfort.

🌸 The reddened area may also be firm, tender, and warm to touch.

🌸 This is why a pie-wedge-shaped area of redness is an important symptom to include.

Fever and flu-like symptoms

🌸 Mastitis often causes systemic symptoms such as fever, chills, malaise, and flu-like body aches.

🌸 These findings occur because the condition is not only inflammatory but often infectious.

🌸 The mother may report feeling suddenly ill in addition to having breast pain.

🌸 Systemic symptoms are especially useful in distinguishing mastitis from simple engorgement.

🌸 Therefore, fever and flu-like symptoms are expected findings.

A small white blister on the tip of the nipple

🌸 A small white blister on the nipple is more consistent with a milk bleb or plugged nipple pore, not mastitis itself.

🌸 Although it may contribute to milk stasis, it is not one of the classic defining signs of mastitis.

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Answer 2

Correct Answers:

Molding.

Rationale :

🔵 Molding refers to the slight overlapping of the fetal cranial bones during labor as the head adapts to the birth canal.

🔵 This process helps the fetal head fit through the maternal pelvis more effectively.

🔵 It is a common and expected finding during vaginal birth.

🔵 The change is usually temporary, and the bones return to their normal position after birth.

🔵 This makes molding the correct term for shaping of the fetal head in labor.

Valsalva maneuver

🔵 The Valsalva maneuver refers to forceful bearing down while holding the breath, not shaping of the fetal skull.

🔵 It is a maternal pushing action, not a fetal cranial change.

Ferguson reflex

🔵 The Ferguson reflex is the urge to push caused by fetal pressure on stretch receptors in the pelvic floor.

🔵 It does not describe overlapping of cranial bones.

Lightening

🔵 Lightening is the descent of the fetal presenting part into the maternal pelvis before labor.

🔵 It is related to fetal position, not skull bone overlapping.

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Answer 3

Correct Answers:

place eye shields over the newborn's closed eyes.

Rationale :

🟣 During phototherapy, the newborn’s eyes must be protected from the bright therapeutic light.

🟣 Eye shields help prevent retinal irritation or damage while the infant receives treatment for hyperbilirubinemia.

🟣 The shields should be placed over the infant’s closed eyes and removed periodically for eye care and assessment.

🟣 Proper eye protection is one of the most important nursing responsibilities during phototherapy.

🟣 This is why placing eye shields over the closed eyes is the appropriate intervention.

Change the newborn's position every 4 hours

🟣 Newborns receiving phototherapy should usually be repositioned more frequently, often every 2 hours, to expose as much skin as possible.

🟣 Waiting 4 hours is longer than ideal for maximizing treatment exposure.

Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea

🟣 Fluid and feeding should not be limited during phototherapy.

🟣 Adequate feeding is important because it promotes hydration and bilirubin excretion through stool.

Apply an oil-based lotion to the newborn's skin to prevent drying and cracking

🟣 Oil-based lotions are not recommended during phototherapy because they can interfere with the effectiveness of the lights and may increase skin heating.

🟣 Routine skin care should be provided without applying oily products.

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Answer 4

Correct Answers:

contractions every 2 to 5 minutes.

Rationale :

🟢 A normal labor pattern is commonly characterized by regular uterine contractions occurring every 2 to 5 minutes.

🟢 This spacing allows effective labor progress while still permitting uterine relaxation and fetal oxygenation between contractions.

🟢 Adequate resting tone between contractions is essential for placental perfusion.

🟢 A pattern in this range is much more consistent with normal active labor than excessively frequent or prolonged contractions.

🟢 Therefore, contractions every 2 to 5 minutes best describe normal uterine activity.

Contractions about 1 minute apart

🟢 Contractions occurring every minute are too frequent and may suggest uterine tachysystole.

🟢 This pattern can compromise fetal oxygenation because there is not enough relaxation time between contractions.

Contractions lasting about 2 minutes

🟢 A normal contraction does not usually last 2 full minutes.

🟢 Contractions that long are excessive and may indicate abnormal uterine activity.

A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg

🟢 These values are not consistent with normal uterine pressure patterns in labor.

🟢 The numbers given are unrealistic for expected contraction intensity and resting tone.

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Answer 5

Correct Answers:

thrombophlebitis; using real-time and color Doppler ultrasound

Rationale :

🟠 Pain, warmth, redness, and a hardened enlarged area in the leg strongly suggest thrombophlebitis, which involves inflammation and clot formation in a vein.

🟠 Postpartum clients are at increased risk because pregnancy and the postpartum state are hypercoagulable.

🟠 Doppler ultrasound is commonly used to confirm the diagnosis by evaluating blood flow and detecting venous obstruction.

🟠 This method is noninvasive and very useful in assessing suspected deep or superficial vein thrombosis.

🟠 Therefore, thrombophlebitis confirmed with Doppler ultrasound is the best answer.

Coagulopathies; drawing blood for laboratory analysis

🟠 Coagulopathies usually present with abnormal bleeding patterns rather than a warm, reddened, tender localized leg lesion.

🟠 The symptoms described are more consistent with a venous clotting disorder, not a generalized bleeding disorder.

Disseminated intravascular coagulation; asking for laboratory tests

🟠 DIC is a systemic clotting and bleeding emergency, not a localized tender leg condition.

🟠 The leg findings in the question are much more characteristic of thrombophlebitis.

Von Willebrand disease; noting whether bleeding times have been extended

🟠 Von Willebrand disease is a bleeding disorder, not the most likely explanation for a hot, red, painful postpartum leg.

🟠 The presentation points to venous inflammation and clot formation instead.

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Answer 6

Correct Answers:

perform fundal massage.

Rationale :

🔴 Uterine atony means the uterus is not contracting effectively after birth, which allows continued bleeding from placental implantation sites.

🔴 Fundal massage is the immediate nursing intervention used to stimulate uterine contraction and reduce hemorrhage.

🔴 A firm contracted uterus compresses the open blood vessels and helps control postpartum bleeding.

🔴 Because uterine atony is the most common cause of postpartum hemorrhage, prompt fundal massage is critical.

🔴 This makes performing fundal massage the priority action.

Prepare the woman for surgical intervention

🔴 Surgical intervention may be necessary if bleeding does not respond to first-line measures, but it is not the immediate primary nursing action.

🔴 The nurse should first attempt to control atony with direct uterine stimulation and other initial measures.

Establish venous access

🔴 Venous access is very important in hemorrhage management, but for bleeding specifically caused by uterine atony, the immediate bedside priority is to stimulate contraction.

🔴 Fundal massage directly addresses the source of the bleeding right away.

Catheterize the bladder

🔴 Emptying the bladder can help the uterus contract better, but it is not the first priority over direct fundal massage.

🔴 The most immediate response to uterine atony is manual uterine stimulation.

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Answer 7

Correct Answers:

stimulate uterine contraction.

Rationale :

🌼 Oxytocic medications such as Pitocin or Methergine are given after delivery of the placenta to promote firm uterine contraction.

🌼 A well-contracted uterus compresses the blood vessels at the placental site and helps prevent postpartum hemorrhage.

🌼 This is one of the most important interventions in the active management of the third stage of labor.

🌼 The goal is not comfort or infection prevention, but effective hemostasis through uterine tone.

🌼 That is why the nurse expects these medications to be given to stimulate uterine contraction.

Relieve pain

🌼 Oxytocics are not administered primarily for pain relief.

🌼 Their major purpose is to improve uterine tone and reduce bleeding.

Prevent infection

🌼 Oxytocics do not function as anti-infective agents.

🌼 They are used to support uterine contraction, not to prevent infection.

Facilitate rest and relaxation

🌼 These medications do not promote rest as their primary effect.

🌼 Their therapeutic role is focused on uterine contraction and hemorrhage prevention.

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Answer 8

Correct Answers:

Assessing for chest discomfort and palpitations

Rationale :

💎 Terbutaline is a beta-adrenergic agonist used as a tocolytic, but it can cause significant cardiovascular side effects.

💎 Common adverse effects include tachycardia, palpitations, chest discomfort, tremors, and nervousness.

💎 Because of these risks, the nurse should carefully monitor the woman’s cardiac response.

💎 Chest discomfort and palpitations may indicate that the drug is causing problematic stimulation.

💎 For this reason, assessing for chest discomfort and palpitations is the correct intervention.

Assessing for bradycardia

💎 Terbutaline is more likely to cause tachycardia, not bradycardia.

💎 Monitoring for a slow heart rate would not be the priority side-effect assessment.

Assessing deep tendon reflexes (DTRs)

💎 DTR assessment is especially important with magnesium sulfate, not terbutaline.

💎 It is not the most relevant monitoring focus for this medication.

Assessing for hypoglycemia

💎 Terbutaline is more commonly associated with hyperglycemia, not hypoglycemia.

💎 Therefore, hypoglycemia is not the key side effect to identify.

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Answer 9

Correct Answers:

ask her to turn to one side.

Rationale :

⭐ When a laboring woman lies supine, the gravid uterus can compress the inferior vena cava and aorta.

⭐ This reduces venous return, lowers maternal cardiac output, and can decrease uteroplacental perfusion.

⭐ Turning to a side-lying position relieves this compression and improves maternal and fetal circulation.

⭐ Left lateral positioning is especially helpful in promoting uterine blood flow.

⭐ Therefore, the most appropriate nursing action is to ask her to turn to one side.

Take her blood pressure

⭐ Blood pressure assessment may be useful, but it does not immediately correct the physiologic problem created by the supine position.

⭐ Position change should come first to reduce aortocaval compression.

Determine whether fetal tachycardia is present

⭐ Fetal assessment is important, but the immediate nursing action is to remove the cause of decreased perfusion.

⭐ Repositioning is the priority intervention.

Elevate her feet and legs

⭐ Elevating the legs does not address the compression of major maternal vessels by the uterus.

⭐ Side-lying is much more effective for improving circulation in labor.

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Answer 10

Correct Answers:

contact between maternal blood and fetal capillaries within the chorionic villi.

Rationale :

🩷 Exchange between mother and fetus occurs at the level of the chorionic villi, where maternal blood surrounds the villi and fetal capillaries lie within them.

🩷 Oxygen, nutrients, and waste products move across the placental membrane by diffusion and other transport processes.

🩷 Maternal and fetal blood normally come into close proximity, but they do not directly mix.

🩷 This arrangement allows efficient exchange while maintaining separate maternal and fetal circulations.

🩷 Therefore, placental exchange is best described as contact between maternal blood and fetal capillaries within the chorionic villi.

Passive diffusion of maternal carbon dioxide and oxygen into the fetal capillaries

🩷 The direction given is inaccurate because oxygen moves from maternal blood to the fetus, but carbon dioxide moves from fetal blood to the mother.

🩷 This statement does not correctly describe placental gas exchange.

A mixture of maternal and fetal blood within the intervillous spaces

🩷 Maternal and fetal blood do not normally mix in the intervillous spaces.

🩷 They remain separated by the placental membrane while exchange occurs across it.

Interaction of maternal and fetal pH levels within the endometrial vessels

🩷 Placental exchange does not occur through an interaction of pH levels within endometrial vessels.

🩷 The key anatomic site of exchange is the chorionic villi, not endometrial vessel pH interaction.

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QLexNursing

1 :
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.)

2 :
The slight overlapping of cranial bones or shaping of the fetal head during labor is called

3 :
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to

4 :
A normal uterine activity pattern in labor is characterized by

5 :
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect? and should confirm the diagnosis by?

6 :
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to

7 :
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to

8 :
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?

9 :
A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to

10 :
The placenta allows exchange of oxygen, nutrients, and waste products between the mother and fetus by

QLexNursing

1 : A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.)

2 : The slight overlapping of cranial bones or shaping of the fetal head during labor is called

3 : A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to

4 : A normal uterine activity pattern in labor is characterized by

5 : A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect? and should confirm the diagnosis by?

6 : A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to

7 : The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to

8 : The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?

9 : A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to

10 : The placenta allows exchange of oxygen, nutrients, and waste products between the mother and fetus by

1 :
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.)

2 :
The slight overlapping of cranial bones or shaping of the fetal head during labor is called

3 :
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to

4 :
A normal uterine activity pattern in labor is characterized by

5 :
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect? and should confirm the diagnosis by?

6 :
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to

7 :
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to

8 :
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?

9 :
A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to

10 :
The placenta allows exchange of oxygen, nutrients, and waste products between the mother and fetus by