A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider (HCP) in two weeks.
Which action should the practical nurse (PN) take?
Recommend that the client wear a supportive bra to prevent leaking of fluid.
Reschedule the client's prenatal appointment for the following day.
Explain that this is normal, but can be assessed further at the next prenatal visit.
Obtain additional data by asking the client if her areolae have become darker.
The Correct Answer is C
Choice A rationale
While wearing a supportive bra can manage symptoms like leaking, it does not address the underlying physiological changes or provide reassurance about their normalcy during pregnancy. The primary concern is to alleviate anxiety and provide accurate information, not just symptom management. Breast changes are common, and this choice does not prioritize assessment or explanation.
Choice B rationale
Rescheduling the appointment prematurely might cause unnecessary anxiety for the client if the symptoms are indeed normal. It disrupts the established prenatal care schedule without sufficient clinical indication. Unless acute distress or clear signs of pathology are present, waiting for the scheduled visit is generally appropriate.
Choice C rationale
During the third trimester, breast tissue undergoes significant hormonal changes in preparation for lactation, leading to increased vascularity, glandular growth, and sometimes the leakage of colostrum, a yellowish fluid. These are normal physiological adaptations, and reassuring the client while noting it for the upcoming visit provides appropriate, evidence-based care.
Choice D rationale
While darkened areolae are another common physiological change during pregnancy due to increased melanocyte-stimulating hormone, asking about it does not directly address the client's current concerns about "lumpy places" or fluid leakage. It's a related but separate observation, and the initial focus should be on explaining the normal changes the client is reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Consumption of whole milk as a toddler is generally appropriate for growth and development, providing essential fats and nutrients. Unless consumed in excessive quantities or as part of an overall diet high in calories without sufficient physical activity, it is not typically identified as a primary singular contributor to early obesity.
Choice B rationale
Dedicated breastfeeding for 6 months is protective against childhood obesity. Breast milk provides optimal nutrition and growth-promoting factors, and breastfeeding is associated with better self-regulation of caloric intake by infants, potentially reducing the risk of later obesity compared to formula feeding.
Choice C rationale
Exclusive soy-based formula for the first year, while an alternative for specific dietary needs, does not inherently contribute to early obesity more than other formulas. The caloric density and nutritional composition of standard infant formulas are regulated and designed to support healthy growth, making it unlikely to be a primary cause of obesity.
Choice D rationale
Introducing solid foods, such as fortified cereal, before 4 months of age is associated with an increased risk of obesity. Infants lack the necessary gastrointestinal and renal maturity to process solids effectively before this age, and early introduction can lead to excessive caloric intake, disruption of feeding cues, and altered gut microbiome development, predisposing to weight gain.
Correct Answer is D
Explanation
Choice A rationale
While postpartum depression is a serious concern, immediately asking about suicidal thoughts without first establishing a broader understanding of the client's feelings can be premature and potentially alienating. It is essential to first assess the general emotional state and bonding difficulties before jumping to severe mental health concerns.
Choice B rationale
Explaining that this is a common feeling can minimize the client's distress and validate her experience, but it does not provide an avenue for her to express her specific concerns or for the PN to fully assess the depth of her feelings. It can prematurely close off further discussion and assessment.
Choice C rationale
Determining if her husband is bonding with the baby shifts the focus away from the client's own feelings and experiences, which is the primary concern in this situation. While partner involvement is important, the immediate priority is to understand and address the client's reported lack of bonding.
Choice D rationale
Encouraging the client to talk about her feelings provides an open and supportive environment for her to express her specific concerns regarding bonding. This allows the practical nurse to gather more information, assess the severity of the issue, and identify appropriate interventions or referrals if needed, promoting therapeutic communication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.