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A client who is breastfeeding tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response from the nurse is which statement.

"I understand your concern, but your baby will be okay."

"Milk normally comes in around the third day.

"You can bottle feed until your milk comes in."

"Your baby seems content, so you should not worry about him getting enough to eat."

Answer and Explanation

The Correct Answer is B

A. "I understand your concern, but your baby will be okay." This response does not provide education or reassurance.

B. "Milk normally comes in around the third day." Correct. This provides factual information to reassure the mother.

C. "You can bottle feed until your milk comes in." Incorrect. Supplementing may reduce breastfeeding success.

D. "Your baby seems content, so you should not worry about him getting enough to eat." This dismisses the mother's concern without providing information.

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Correct Answer is C

Explanation

A. Prolonged bed rest increases the risk of thrombus formation. Pain management should not encourage inactivity.

B. While preventing excessive exertion is important, encouraging movement is essential for preventing thrombosis.

C. Correct. Early ambulation promotes circulation and reduces the risk of deep vein thrombosis (DVT).

D. Strict bed rest increases the risk of thromboembolism and is not recommended postpartum unless medically indicated.

A. No intervention is needed at this time. 200 ML is adequate output. B. Notify the provider immediately of urinary retention. C. Notify the provider if the client does not void in 24 hours. D. Encourage the client to consume more fluids.

Correct Answer is B

Explanation

A. Incorrect. 200 mL of urine in 12 hours is inadequate postpartum output and may indicate urinary retention.

B. Correct. A distended bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The provider should be notified, and interventions such as catheterization may be necessary.

C. Incorrect. Waiting 24 hours before intervention is inappropriate when urinary retention is already evident.

D. Encouraging fluids is helpful, but it does not directly address the immediate concern of a distended bladder.

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A client who is breastfeeding tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response from the nurse is which statement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a care plan for her 12-hour postpartum patient which include prevention of thrombosis. During implementation, the nurse is expected to

Correct Answer is C

Explanation

A nurse is caring for a client at 12 hours postpartum who has voided a total of 200 ml. Upon assessment the nurse notes that the bladder is distended. What is the priority intervention by the nurse?

Correct Answer is B

Explanation

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