As part of the postpartum assessment, the nurse examines the breasts of a primiparous (first baby) breastfeeding woman who is 1 day postpartum. Which of the following findings should the nurse anticipate?

Soft, nontender, colostrum is present.

Swollen, warm, and tender upon palpation.

Leakage of milk at let-down. At let-down

A few blisters and bruise on each areola.

Answer and Explanation

The Correct Answer is B

A) Soft, nontender, colostrum is present:
In the early postpartum period, specifically on day 1, the woman is still in the process of transitioning from producing colostrum (a thick, yellowish fluid rich in antibodies) to mature breast milk. The colostrum may be present, but the breasts are typically not soft and nontender. Instead, they are more likely to be swollen and tender as the milk production ramps up. Therefore, this is not the typical finding on day 1 postpartum.
B) Swollen, warm, and tender upon palpation:
This is the expected finding on day 1 postpartum, especially for a primiparous woman. After childbirth, the breasts begin the transition from producing colostrum to mature breast milk. The increased blood flow and milk production cause the breasts to become swollen, warm, and tender to the touch. This condition is often referred to as engorgement, which is common within the first few days after delivery, particularly in breastfeeding mothers. Engorgement usually peaks around day 3 but may begin to occur slightly earlier, as the body adjusts to milk production.

C) Leakage of milk at let-down:
This finding is more typical of a woman who is further along in the postpartum period, usually after her milk has transitioned from colostrum to mature milk. Milk let-down and the associated leakage typically occur later, often after a few days (around day 3 or later). On day 1, the milk supply is still establishing itself, and leakage is less common.

D) A few blisters and bruises on each areola:
Blisters and bruises on the areola could indicate improper latch or trauma from breastfeeding. This is not a typical or expected finding in a woman who is only 1 day postpartum. If this occurs, the nurse should assess the infant’s latch and the breastfeeding technique to prevent further complications. Such findings should be addressed promptly, but they are not considered normal on day 1.

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Correct Answer is A

Explanation

A) Abdominal with synchronous chest movements:
Newborns primarily exhibit abdominal breathing, meaning that the diaphragm does most of the work while the chest movements are less pronounced. This is normal for full-term neonates, and the chest and abdomen move in a synchronous manner as the baby breathes. This pattern is indicative of an immature respiratory system that is still developing, but it is completely normal in the early stages of life.

B) Chest breathing with nasal flaring:
While some chest movement is observed in newborns, the primary pattern of breathing is abdominal. Nasal flaring is generally an abnormal sign in newborns and may indicate respiratory distress, such as when there is an obstruction in the airway or a need for increased oxygen intake. It is not considered a normal, healthy breathing pattern in newborns.

C) Diaphragmatic with chest retraction:
Diaphragmatic breathing is normal, but chest retraction is not. Retractions occur when there is increased effort to breathe, and they typically indicate respiratory distress or obstruction. In a healthy, full-term newborn, retractions should not be present. This type of breathing would require further investigation to rule out conditions like respiratory distress syndrome or infection.

D) Deep with a regular rhythm:
Newborns may have irregular breathing patterns, including periods of apnea (a few seconds without breathing) and slight irregularity in rhythm, especially during sleep. Deep, regular breathing without any irregularities is not typical in a newborn, and any consistent deep breathing would require further observation to rule out any potential underlying issues.

A. Apply ice to the perineal area for the first 12-24 hours. B. Apply warm packs to the perineal area for the first 24-48 hours. C. Encourage sitz baths at least twice a day D. Use a topical antiseptic cream or spray on the perineal area. E. Obtain an order for an indwelling urinary catheter.

Correct Answer is ["A","C"]

Explanation

A) Apply ice to the perineal area for the first 12-24 hours:
Applying ice to the perineal area in the first 12-24 hours after delivery is a common intervention for promoting comfort, especially for lacerations or episiotomies. The cold helps to reduce swelling and inflammation, and it numbs the area, providing pain relief. Ice also helps to constrict blood vessels, reducing blood flow to the affected area, which can prevent excessive bleeding and promote healing.

B) Apply warm packs to the perineal area for the first 24-48 hours:
Warm packs are generally not used in the first 24-48 hours after delivery for a laceration. Heat can increase blood flow, which is not ideal immediately after birth when the risk of swelling and bleeding is higher. Typically, warm packs are more beneficial after the first 48 hours to improve circulation and promote healing. Therefore, this is not the best intervention in the immediate postpartum period for a labial laceration.

C) Encourage sitz baths at least twice a day:
Sitz baths are highly effective for postpartum comfort, particularly for perineal trauma such as lacerations or episiotomies. A sitz bath helps to cleanse the area and promote relaxation, reducing discomfort. It also enhances circulation to the perineum, which can speed up healing. Encouraging sitz baths at least twice a day is a helpful intervention for postpartum care and is appropriate for a labial first-degree laceration.

D) Use a topical antiseptic cream or spray on the perineal area:
While topical antiseptics may help reduce infection risk, they are generally not necessary for most first-degree lacerations, especially if they are uncomplicated. In fact, overuse of antiseptics or antibiotic creams can irritate the sensitive tissue in the perineal area and delay healing. The focus should be on keeping the area clean and dry, using gentle care. Therefore, this intervention is not typically recommended for a labial laceration.

E) Obtain an order for an indwelling urinary catheter:
An indwelling urinary catheter is usually only needed in specific cases, such as when a woman is unable to void postpartum due to perineal trauma, epidural anesthesia, or bladder retention. In the case of a labial first-degree laceration, there is no indication for an indwelling catheter unless the woman is unable to void on her own. The best approach is to encourage frequent voiding and assist with comfortable positioning.

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As part of the postpartum assessment, the nurse examines the breasts of a primiparous (first baby) breastfeeding woman who is 1 day postpartum. Which of the following findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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