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 D

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions won't elicit clear answers.

B. Share personal values to put the client at ease: While building rapport is important, sharing personal values might not be necessary.

C. Get the most difficult questions over with first: This can make the client defensive and less likely to be honest.

D. Begin with less sensitive questions: Starting with general questions about lifestyle habits and then gradually transitioning to more specific questions about alcohol and substance use can create a more comfortable environment for open communication

A. "Would you like to talk about what is bothering you?" B. "Do you feel like practicing insulin injections now?" C. "I know you are afraid, but I am here to help you." D. "Before you can go home you must learn how to give insulin."

Correct Answer is A

Explanation

A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.

B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.

C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.

D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.

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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

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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