A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate?

Correct Answer: B

Rationale: The correct answer is B) Encourage the woman to breastfeed frequently. Rationale: Encouraging the woman to breastfeed frequently on the affected breast helps to empty the breast and prevent milk stasis, which can worsen mastitis. Continued breastfeeding also helps in clearing the infection and promoting faster recovery. It is safe for the infant to breastfeed from the affected breast as the milk is still safe for the baby. Option A) advising the woman to apply ice packs to her breasts is incorrect as ice packs can worsen the condition by decreasing milk flow and causing further stasis. Option C) informing the woman to wean immediately is not recommended as breastfeeding should continue to help clear the infection and prevent further complications. Option D) directing the woman to notify her pediatrician is not the priority in this situation. The woman should be guided on appropriate nursing interventions to manage mastitis effectively. Educational Context: Teaching nursing interventions for mastitis is crucial in providing comprehensive care to breastfeeding mothers. Educating on the importance of continued breastfeeding, proper latch techniques, frequent nursing, and ensuring adequate rest and hydration are key components in managing mastitis effectively and promoting successful breastfeeding.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Absent bowel sounds. A paralytic ileus is a temporary lack of movement in the intestines following surgery, which can lead to absent bowel sounds. This occurs due to the disruption of normal peristalsis in the bowel. Option A) Abdominal striae refers to stretch marks on the abdomen and is not indicative of a paralytic ileus. Option B) Oliguria is a decreased urine output and is not directly related to bowel function. Option C) Omphalocele is a congenital abdominal wall defect and is not relevant to the assessment of a paralytic ileus post-cesarean section. Educationally, understanding the significance of assessing bowel sounds post-operatively is crucial for nurses caring for post-cesarean section clients. Recognizing signs of a paralytic ileus promptly can prevent complications such as bowel perforation or obstruction. Nurses should perform regular abdominal assessments and auscultate for bowel sounds to monitor bowel function and detect any abnormalities early.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Postural headache. The nurse should monitor the client who had spinal anesthesia for the development of a postural headache, which is a common complication associated with spinal anesthesia due to cerebrospinal fluid leakage. This occurs when the client changes position, usually when sitting or standing, and is relieved when lying down. Pruritus (A) and nausea (B) are common side effects of both spinal and epidural anesthesia and do not differentiate between the two types of anesthesia. Respiratory depression (D) is a serious complication associated with opioid medications used in epidural anesthesia but is not typically a concern with spinal anesthesia. Educationally, understanding the differences in complications between spinal and epidural anesthesia is crucial for nurses caring for postoperative cesarean clients to provide safe and effective care. Recognizing the unique risks associated with each type of anesthesia allows nurses to anticipate, assess, and manage potential complications promptly.

Correct Answer: B

Rationale: The correct answer is B) Notify the obstetrician of the findings. This action is appropriate because the client's vital signs and reflexes are indicating signs of postpartum hypertension, which can be a serious condition requiring medical attention. The elevated blood pressure (150/100) along with other vital sign changes and the administration of Pitocin make it crucial to involve the obstetrician for further evaluation and management. Option A) Nothing because the results are normal is incorrect as the vital signs and reflex changes indicate a deviation from normal and require intervention. Option C) Discontinue the intravenous immediately is incorrect because stopping the IV without proper assessment and guidance from the healthcare provider could lead to adverse outcomes for the client. Option D) Reassess the client after fifteen minutes is not the best choice in this situation since the client is showing signs of postpartum hypertension which requires immediate attention. Educationally, this scenario highlights the importance of recognizing abnormal postpartum vital signs and the need for timely communication with the healthcare team. It emphasizes the critical role of the nurse in monitoring and advocating for the well-being of the postpartum client, especially in identifying and addressing potential complications such as postpartum hypertension.