On the first postpartum day, the nurse examines a new mother’s breasts.
What condition is the nurse most likely to find?

Soft, with no change from before delivery.

Filling and secreting colostrum.

Slightly firm with an immediate let-down response.

Firm, larger, and very tender to touch.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.

Choice B rationale

On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.

Choice C rationale

An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.

Choice D rationale

While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.

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Correct Answer is A

Explanation

Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.

A. Manual resuscitation bag B. An advanced airway kit C. A dose of subcutaneous epinephrine D. The child’s favorite toy E. Nebulized albuterol

Correct Answer is B

Explanation

The correct answer is choice A. Manual resuscitation bag and B. An advanced airway kit.

Choice A rationale:

A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure or arrest. This device allows healthcare providers to manually deliver breaths to the patient, ensuring adequate oxygenation and ventilation until more advanced airway management can be established.

Choice B rationale:

An advanced airway kit is crucial for managing a difficult airway, especially in pediatric patients who may have anatomical differences making intubation challenging. This kit typically includes tools for endotracheal intubation, laryngeal mask airways, and other devices to secure the airway and ensure the child can breathe effectively.

Choice C rationale:

A dose of subcutaneous epinephrine is primarily used for treating severe allergic reactions or anaphylaxis. While it is a critical medication in emergencies involving anaphylaxis, it is not directly related to the immediate need for airway management and ventilation in this scenario.

Choice D rationale:

The child’s favorite toy can be helpful in calming and distracting the child during medical procedures, reducing anxiety and making the experience less traumatic. However, it is not a medical necessity for the placement of an intravenous line or for managing respiratory distress.

Choice E rationale:

Nebulized albuterol is used to treat bronchospasm and wheezing, commonly seen in asthma or reactive airway disease. While it is an important medication for managing respiratory symptoms, it does not address the immediate need for airway management and ventilation support in a critical situation.

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On the first postpartum day, the nurse examines a new mother’s breasts. What condition is the nurse most likely to find?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot. What is the most important action for the nurse to perform?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Choice E rationale:

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The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse expect?

On the first postpartum day, the nurse examines a new mother’s breasts.
What condition is the nurse most likely to find?