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?
Within 2 days after delivery.
In about 10 days after delivery.
In 3 to 5 days after delivery.
In 6 to 8 days after delivery.
The Correct Answer is C
Choice A rationale
Within 2 days after delivery is not the typical timeframe for breast milk to come in. Colostrum, the first milk, is produced immediately after birth, but mature milk usually comes in a few days later.
Choice B rationale
In about 10 days after delivery is too late for the onset of mature breast milk. Most women experience their milk coming in within the first week postpartum.
Choice C rationale
In 3 to 5 days after delivery is the correct response. This is the typical timeframe for the transition from colostrum to mature milk. During this period, the breasts may feel fuller and heavier as milk production increases.
Choice D rationale
In 6 to 8 days after delivery is later than the usual timeframe for breast milk to come in. While there can be some variation, most women experience their milk coming in within 3 to 5 days postpartum.
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Correct Answer is D
Explanation
Choice A rationale
Staying home until one week after delivery is not a specific intervention for postpartum depression. Social support and monitoring are more effective strategies.
Choice B rationale
While adequate rest is important, advising to sleep as much as possible is not a targeted intervention for postpartum depression. Structured support and counseling are more beneficial.
Choice C rationale
Returning to work two weeks after delivery is not advisable for someone with a history of postpartum depression. Early return to work can increase stress and exacerbate symptoms.
Choice D rationale
Contacting a crisis counselor once a week provides structured support and monitoring, which is crucial for managing postpartum depression. Regular counseling helps in early identification and management of symptoms.
Correct Answer is B
Explanation
Choice A rationale
Placing the client on seizure precautions is not appropriate for shaking chills during the immediate postpartum period. Shaking chills are a common physiological response after childbirth due to hormonal changes and the body’s effort to regulate temperature. Seizure precautions are reserved for clients with a history of seizures or those exhibiting signs of a seizure disorder.
Choice B rationale
Covering the client with warm blankets is the correct action. Shaking chills are often due to the body’s attempt to regain thermal balance. Providing warmth with blankets helps to alleviate the chills and provide comfort to the client.
Choice C rationale
Determining the client’s temperature is important but not the immediate action to take. While it is necessary to monitor for fever, which could indicate an infection, the priority is to provide comfort and warmth to the client experiencing chills.
Choice D rationale
Notifying the charge nurse is not the immediate action required. The nurse should first address the client’s immediate need for warmth and comfort. If the chills persist or are accompanied by other concerning symptoms, then notifying the charge nurse would be appropriate.