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. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).
B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.
C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.
D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.
Correct Answer is D
Explanation
A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.
B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.
C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.
D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.
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