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 A
Explanation
Choice A rationale
The client needs a second varicella vaccination at her postpartum visit to ensure full immunity. The initial dose provides partial immunity, and the second dose completes the vaccination series.
Choice B rationale
The client needs to use contraception for 1 month, not 3 months, before considering pregnancy after receiving the varicella vaccine. This is to prevent potential harm to a developing fetus.
Choice C rationale
The varicella vaccine is not given based on the baby’s blood type. It is administered to protect the client from varicella infection.
Choice D rationale
There is no need for testing to see if the client has developed immunity after receiving the varicella vaccine. The second dose is given to ensure full immunity.
Correct Answer is B
Explanation
Choice A rationale
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.