Maternal Newborn Nursing Examination – Rationale Samples

Question

Breast engorgement occurs in lactating women because breast milk is

  • produced in excessive quantity
  • produced too rapidly
  • removed too slowly

Rationale

Breast engorgement is a risk for any breastfeeding woman. The best course of action is prevention by encouraging frequent feeding early on. When breast engorgement occurs, it is due to the increased blood flow and lymphatic supply to the breast. It is not due to overproduction of milk, but because the milk is not being rapidly removed.

Question

A woman at eight hours postpartum is noted to void frequently, but in amounts of approximately 70–100 cc each time. The nurse should

  • catheterize the woman for residual
  • obtain an order for anticholinergic drug
  • palpate for costovertebral angle tenderness

Rationale

Catheterization is required when a woman is voiding small amounts (<100 mL) frequently. Anticholinergics are used for urge incontinence and costovertebral angle tenderness is evaluated to rule out pyelonephritis, neither of which are apparent in this clinical scenario.