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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cries vigorously when stimulated. A vigorous cry is a positive sign that the infant's lungs are functioning well and that they are receiving adequate oxygenation, indicating a good transition to extrauterine life.
B. Heart rate of 220 beats/minute. A heart rate of 220 beats/minute is too high for a newborn and could indicate tachycardia or distress, not a normal transition.
C. A positive Babinski reflex. A positive Babinski reflex is a normal finding in newborns but is not directly related to their immediate transition to extrauterine life. It is a neurological reflex that indicates normal nervous system function.
D. Flexion of all four extremities. Flexion of all four extremities is a good sign of normal muscle tone and neurological function but does not directly indicate respiratory or circulatory adaptation to extrauterine life as clearly as a vigorous cry does.
Correct Answer is B
Explanation
A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.
B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.
C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.
D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.
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