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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

A. Determine degree of skin elasticity. B. Measure muscle size and strength. C. Inspect appearance of the spine. D. Note 24-hour fluid intake and output.

Correct Answer is B

Explanation

A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

View Question and Answer

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

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

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

Correct Answer is B

Explanation

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

While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

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

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

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?