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

Firm, larger, and very tender to touch.

Soft, with no change from before delivery.

Filling and secreting colostrum.

Slightly firm with immediate let-down response.

Answer and Explanation

The Correct Answer is C

A. Firm, larger, and very tender to touch. This option describes the characteristics of engorged breasts, which typically occur a few days after birth as milk production increases and the breasts become full. Engorged breasts can feel firm, swollen, and tender to the touch due to the increased blood flow and milk accumulation. However, on the first postpartum day, engorgement may not yet be fully developed.

B. Soft, with no change from before delivery. This option is unlikely as the breasts typically undergo changes during the postpartum period, especially with the initiation of lactation. Soft breasts with no change from before delivery would not be expected on the first postpartum day.

C. Filling and secreting colostrum. This option is the most likely finding on the first postpartum day. Colostrum, the early milk produced by the breasts, begins to be secreted during the late stages of pregnancy and continues after birth. On the first postpartum day, the breasts may be filling with colostrum, which is typically thicker and more concentrated than mature breast milk. It is produced in small amounts, about 40-50ml on the first day but that is all an infant normally needs at this time.

D. Slightly firm with immediate let-down response. While some firmness may be present due to the initiation of lactation, an immediate let-down response is less likely on the first postpartum day. The let-down reflex, which triggers the release of milk from the breast, may take some time to establish and may not occur immediately after delivery.

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Correct Answer is A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

A. Multiple maculopapular pustules over forehead and chin on an adolescent student. B. Red, swollen, painful nodule located on the upper back of a school aged student. C. Small, white flecks on the hair shafts throughout scalp on a school aged child. D. Bilateral patellar abrasions with eschar formation on a preschool aged student.

Correct Answer is B

Explanation

A. Multiple maculopapular pustules over forehead and chin on an adolescent student: These pustules could be indicative of an infectious process, such as acne or impetigo. While not necessarily an emergency, it’s important to assess and potentially treat these skin lesions promptly. The school nurse should report this to the healthcare provider for further evaluation.

B. Red, swollen, painful nodule located on the upper back of a school-aged student: This finding raises concern for an abscess or localized infection. The pain, redness, and swelling suggest an inflammatory process. The nurse should promptly report this to the healthcare provider for assessment and appropriate management.

C. Small, white flecks on the hair shafts throughout the scalp on a school-aged child: These white flecks are likely nits (lice eggs). While not an emergency, they do require attention. The nurse should inform the parents or guardians and recommend appropriate treatment. However, this finding does not necessitate immediate reporting to the healthcare provider.

D. Bilateral patellar abrasions with eschar formation on a preschool-aged student: Abrasions with eschar (dead tissue) formation can indicate a deeper injury. The nurse should report this to the healthcare provider promptly for assessment and wound care recommendations.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

Correct Answer is B

Explanation

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Which assessment finding supports the client statement, "My feet swell all the time?"

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?