A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make?
In 3 to 5 days after delivery
In 6 to 8 days after delivery
Within 2 days after delivery
In about 10 days after delivery
The Correct Answer is A
Choice A reason: In 3 to 5 days after delivery is correct, as this is the average time for breast milk production to begin after birth. Breast milk production is stimulated by the drop in progesterone levels that occurs after the placenta is delivered, as well as by the suckling of the baby. The nurse should encourage the client to breastfeed frequently and effectively to promote milk production and prevent engorgement.
Choice B reason: In 6 to 8 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
Choice C reason: Within 2 days after delivery is incorrect, as this is a shorter than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should educate the client that before breast milk comes in, the breasts produce colostrum, which is a thick, yellowish fluid that contains antibodies and nutrients for the baby.
Choice D reason: In about 10 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Checking the consistency of the client's uterine fundus is the first action the nurse should take, as it can indicate the cause of excessive bleeding. A boggy or soft fundus indicates uterine atony, which is the most common cause of postpartum hemorrhage. The nurse should massage the fundus until it becomes firm and contracted.
Choice B reason:
Having the client use the bedpan to urinate is an important action, as a full bladder can displace the uterus and prevent it from contracting properly. However, this is not the first action the nurse should take, as it does not address the immediate source of bleeding.
Choice C reason:
Increasing the client's fluid intake is an important action, as it can help replace fluid loss and prevent hypovolemia and shock. However, this is not the first action the nurse should take, as it does not stop the bleeding.
Choice D reason:
Preparing to administer oxytocic medication is an important action, as it can stimulate uterine contractions and reduce bleeding. However, this is not the first action the nurse should take, as it requires a provider's prescription and may not be necessary if fundal massage is effective.
Correct Answer is B
Explanation
Choice A reason: Hematuria is blood in the urine. It is not a symptom of endometritis, which is an inflammation or infection of the uterine lining. Hematuria can have many other causes, such as urinary tract infections, kidney stones, bladder cancer, or trauma.
Choice B reason: Pelvic pain is one of the most common symptoms of endometritis. It can be caused by the inflammation or infection of the uterine lining, which can also spread to other pelvic organs. Pelvic pain can be dull, sharp, cramping, or constant, and it may worsen with movement or intercourse¹³.
Choice C reason: Pink lochia is normal vaginal discharge after childbirth. It consists of blood, mucus, and tissue from the uterus. It usually lasts for a few weeks and gradually changes color from red to pink to brown to white. Pink lochia is not a sign of endometritis, unless it is foul-smelling, heavy, or persists beyond six weeks.
Choice D reason: Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a symptom of endometritis, which can cause fever and tachycardia (fast heart rate). Bradycardia can have many other causes, such as heart disease, medication side effects, hypothyroidism, or electrolyte imbalance.
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