On the first postpartum day, the nurse examines a new mother’s breasts.
What condition is the nurse most likely to find?
Soft, with no change from before delivery.
Filling and secreting colostrum.
Slightly firm with an immediate let-down response.
Firm, larger, and very tender to touch.
Firm, larger, and very tender to touch.
The Correct Answer is B
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While inspecting the infant’s ears daily can help detect signs of an ear infection early, it does not prevent recurrent otitis media.
Choice B rationale
Positioning the infant prone after feeding does not prevent recurrent otitis media and can actually increase the risk of sudden infant death syndrome.
Choice C rationale
While breastfeeding frequently can provide numerous health benefits for the infant, it does not specifically prevent recurrent otitis media.
Choice D rationale
Avoiding exposure to smoke can help prevent recurrent otitis media in infants. Smoke can irritate the Eustachian tubes, which can lead to fluid buildup and increase the risk of ear infections.
Correct Answer is C
Explanation
Choice A rationale
Administering oxygen via a facemask is an intervention that can be used if the baby shows signs of distress or if the decelerations do not improve with other interventions. However, it is not the first action that should be taken.
Choice B rationale
Turning off the oxytocin infusion could be an appropriate action if the mother is receiving oxytocin and the baby is showing signs of distress. However, it is not the first action that should be taken.
Choice C rationale
Changing the client’s position is the correct first action for variable decelerations. This can relieve potential cord compression and improve fetal oxygenation.
Choice D rationale
Assessing cervical dilation is an important part of monitoring labor progress, but it is not the first action that should be taken in response to variable decelerations.
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