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Multiple Choice Questions 2-1 for Bloody nipple discharge in a lactating patient

Learning Objectives

  1. Describe the pathophysiology of bloody nipple discharge in a lactating patient
  2. Differentiate between normal and concerning breast/chest assessment findings in a lactating patient with bloody nipple discharge
  3. Differentiate between a normal and concerning clinical presentation of nipple discharge in a lactating patient

Question 1

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

When obtaining this patient’s medical history, which of the following is the most important in evaluating the chief complaint?  

 

Question 2

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

When performing a breast/chest assessment for this patient, which of the following would be most concerning for an underlying malignancy?

 

Question 3

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

If during a breast/chest assessment you were able to elicit discharge from the nipple of this patient, which of the following images of nipple discharge would be most concerning for an underlying breast malignancy?

 

Question 4

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

Which of the following breast changes would be considered normal in a lactating woman during the first few weeks postpartum?

 

Question 5

A 27-year-old first time mother presents on day 6 postpartum with a history of bilateral, blood-tinged breast milk collected while using her breast pump. The patient had a spontaneous, vaginal delivery at 39 weeks and 3 days to a baby girl weighing 7 pounds, 10 ounces. Pregnancy, labor, delivery, and postnatal course were uncomplicated. The patient breastfed within the first hour of life and her milk came in by 72 hours postpartum. Because breastfeeding was painful for her, she started pumping on day 3 and giving her baby breast milk by bottle. The breastfeeding pain resolved on day 5 and she has not used the breast pump in the last 24 hours. At the infant’s pediatric visit on day 5 of life, the newborn was at 3% below birth weight. The mother’s grandmother died of breast cancer in her 80s. The patient is a non-smoker and reports no alcohol or drug use. She lives with her boyfriend, the father of the baby in an apartment and plans to stay home with the baby and not return to work.

Which of the following biological processes is most likely involved in the clinical presentation of the patient presented in this case? 

Multiple Choice Questions 2-1 for Bloody nipple discharge in a lactating patient 

Learning Objectives

  1. Identify concerning clinical findings for a neonate whose mother has delayed lactogenesis II
  2. Describe abnormal growth and development of the newborn in the first week postpartum
  3. Identify inadequate breastfeeding practices in the first week postpartum
  4. Differentiate between causes of neonatal jaundice in the first week postpartum
  5. Review patient-centered communication strategies when interacting with the mother-infant dyad

Question 1

An anxious first time mother calls for your advice about her 7-day-old female infant. Which of the following statements from this mother would be a cause for concern? 

 

Question 2

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers.

When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. What additional question would be most helpful in assessing the feeding difficulties in this maternal-fetal dyad?

 

Question 3

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.  

What is the appropriate response? 

 

Question 4

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.

The mother explains that the newborn was born vaginally at 37 weeks gestation with a birth weight of 6 lb, 9 oz (2.97 kg). Labor was uncomplicated and mother and baby were released after 56 hours. When looking through the medical records, you see that total serum bilirubin at 56 h was 10.2 mg/dL. At the pediatrician appointment on day 4 pp, the infant was not distressed and no facial anomalies were noted. She was afebrile with HR 130 bpm, RR 42, weight 5 lb 14 oz (2.65 kg). Bilirubin was 14.8 mg/dL (normal < 2 mg/dL). The mother was advised to continue breastfeeding. Why is the bilirubin increasing? 

 

Question 5

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.

The mother explains that the newborn was born vaginally at 37 weeks gestation with a birth weight of 6 lb, 9 oz (2.97 kg). Labor was uncomplicated and mother and baby were released after 56 hours. When looking through the medical records, you see that total serum bilirubin at 56 h was 10.2 mg/dL. At the pediatrician appointment on day 4 pp, the infant was not distressed and no facial anomalies were noted. She was afebrile with HR 130 bpm, RR 42, weight 5 lb 14 oz (2.65 kg, weight change ~ 10.7%). Bilirubin was 14.8 mg/dL (normal < 2 mg/dL). The mother was advised to continue breastfeeding.

The mother mentions that her breasts started feeling very full yesterday and the baby is refusing to latch. What is your recommendation?