A nurse is assessing a client for postpartum infection.
Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?
Pelvic pain and fatigue.
Light amount of dark red lochia with a bloody odor.
Hematuria.
A localized area of breast tenderness.
The Correct Answer is A
Choice A rationale
Pelvic pain and fatigue can be indicators of endometritis, an infection of the uterine lining. It often manifests with pain, fever, and general malaise, and requires further evaluation and intervention.
Choice B rationale
Light amount of dark red lochia with a bloody odor is a normal postpartum finding. Lochia progresses through different stages, and dark red lochia, which occurs in the later stages, typically has a bloody odor.
Choice C rationale
Hematuria, or the presence of blood in the urine, is not a typical symptom of endometritis. It may indicate a urinary tract infection or other renal issues instead.
Choice D rationale
A localized area of breast tenderness may indicate mastitis, an infection of the breast tissue. It is not related to endometritis but requires attention and treatment.
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Correct Answer is C
Explanation
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.
Correct Answer is D
Explanation
Choice A rationale
A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.
Choice B rationale
Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.
Choice C rationale
Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.
Choice D rationale
Age less than 25 years is not a risk factor for breast cancer; risk increases with age.