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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.

A. Keeps plastic bags of ice in the freezer. B. Wears extra pads when playing football. C. Serves as a counselor at a camp for hemophiliacs. D. Chews food slowly to prevent injury to the gums.

Correct Answer is C

Explanation

Choice A rationale

Keeping plastic bags of ice in the freezer is not specifically indicative of successful management of hemophilia. While ice can be used to manage acute joint bleeds, it does not reflect the overall management of the condition.

Choice B rationale

Wearing extra pads when playing football could indicate an awareness of the risk of injury, but it does not necessarily reflect successful management of hemophilia. In fact, contact sports like football are generally not recommended for individuals with hemophilia due to the risk of bleeding.

Choice C rationale

Serving as a counselor at a camp for hemophiliacs could indicate successful management of hemophilia. It suggests that the individual has not only learned to manage their own condition, but is also able to provide guidance and support to others with the same condition.

Choice D rationale

Chewing food slowly to prevent injury to the gums is a precautionary measure, but it does not necessarily indicate successful management of hemophilia.

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On the first postpartum day, the nurse examines a new mother’s breasts. What condition is the nurse most likely to find?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD. Which statement(s) made by the caregiver demonstrates an understanding?

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A parent rushes their pre-school age child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

The nurse is reviewing the patient’s condition and vital signs following the placement of a 5% dextrose intravenous line. Which medications should the nurse anticipate the healthcare provider will order? Select all that apply.

A laboring client has a variable deceleration on the fetal monitor. What is the first action that the nurse should take?

A newborn’s assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

On the first postpartum day, the nurse examines a new mother’s breasts.
What condition is the nurse most likely to find?