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. Vaginal discharge, presence of genital warts, abdominal tenderness. B. Urinary frequency, unsteady gait, dental enamel erosion. C. Breast tenderness, tremors, high blood pressure. D. Body weight, hirsutism, thyroid enlargement.

Correct Answer is D

Explanation

A. Vaginal discharge, presence of genital warts, abdominal tenderness: While assessing for vaginal discharge and genital warts is important, they are not directly related to the menstrual irregularity described by the client. Abdominal tenderness may be relevant but is not the priority.

B. Urinary frequency, unsteady gait, dental enamel erosion: These symptoms are not specifically associated with missed periods. They may indicate other health issues, but they do not address the primary concern.

C. Breast tenderness, tremors, high blood pressure: Breast tenderness can be related to hormonal changes and menstrual irregularities. Tremors and high blood pressure are less likely to be directly connected to missed periods but should still be assessed.

D. Body weight, hirsutism, thyroid enlargement: Hirsutism (excessive hair growth) and thyroid enlargement (goiter) can be associated with hormonal imbalances, including conditions affecting the menstrual cycle. Assessing body weight is also relevant.

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

Correct Answer is D

Explanation

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

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

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?