A client has been diagnosed with postpartum psychosis. Which of the following actions should the nurse take? Select one:
Maintain the client on strict bedrest.
Carefully monitor intake and output.
Restrict visitation of the client's partner.
Closely supervise all infant care and interaction.
The Correct Answer is D
Choice A Reason: Maintain the client on strict bedrest. This is an inappropriate action that may worsen the client's condition and increase her isolation and depression. Postpartum psychosis requires prompt psychiatric treatment with medication and psychotherapy, not bedrest.
Choice B Reason: Carefully monitor intake and output. This is an irrelevant action that has no direct relation to postpartum psychosis or its management. Monitoring intake and output may be indicated for other postpartum complications such as hemorrhage, infection, or preeclampsia.
Choice C Reason: Restrict visitation of the client's partner. This is an unnecessary action that may deprive the client of social support and emotional comfort. The partner may be an important source of help and information for the client and the health care team. The partner should be involved in the client's care and education, unless there are signs of abuse or violence.
Choice D Reason: Closely supervise all infant care and interaction. This is because postpartum psychosis is a severe mental disorder that occurs in some women after childbirth, which can cause delusions, hallucinations, paranoia, mood swings, confusion, and suicidal or homicidal thoughts. Postpartum psychosis can pose a danger to both the mother and the infant, as the mother may harm herself or the infant due to distorted perceptions or impulses. The nurse should closely supervise all infant care and interaction to ensure safety and prevent injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Insulin needs decrease in the first trimester, but increase in the second trimester as the woman's body becomes more insulin-resistant. This is because this statement describes the typical patern of insulin requirements during pregnancy for women with pre-existing diabetes. Insulin needs decrease in the first trimester due to increased insulin production by the pancreas, increased insulin sensitivity by the tissues, and increased risk of hypoglycemia due to nausea and vomiting. Insulin needs increase in the second trimester due to increased levels of placental hormones such as human placental lactogen (hPL), which antagonize insulin action and cause insulin resistance.
Choice B Reason: Vascular disease that always accompanies diabetes slows fetal growth. This is an incorrect answer that makes a false and exaggerated claim about diabetes and fetal growth. Vascular disease does not always accompany diabetes, but it can be a complication of long-term or poorly controlled diabetes that affects blood vessels and circulation. Vascular disease can affect fetal growth by reducing placental perfusion and oxygen delivery, but it is not the only factor that influences fetal growth. Other factors include maternal nutrition, genetics, infections, or anomalies.
Choice C Reason: The risk of ketoacidosis decreases during the length of the pregnancy. This is an incorrect answer that contradicts the evidence and guidelines on diabetes and ketoacidosis during pregnancy. Ketoacidosis is a metabolic emergency where high levels of ketones accumulate in the blood due to insufficient insulin or excessive glucose utilization, which causes acidosis, dehydration, electrolyte imbalance, and coma. Ketoacidosis can occur in women with diabetes during pregnancy due to infection, stress, starvation, or inadequate insulin therapy. The risk of ketoacidosis does not decrease during the length of the pregnancy, but rather increases in the second and third trimesters due to increased insulin resistance and glucose production.
Choice D Reason: The baby is likely to have a congenital abnormality because of the uncontrolled diabetes. This is an incorrect answer that implies a negative and deterministic outcome for the baby. Congenital abnormalities are structural or functional defects that are present at birth, which can affect various organs or systems in the baby.
Congenital abnormalities can be caused by genetic or environmental factors, or a combination of both. Diabetes can increase the risk of congenital abnormalities, especially if the blood glucose levels are high during the first trimester, when organogenesis occurs. However, the risk of congenital abnormalities is not inevitable or predictable, and it can be reduced by maintaining good glycemic control before and during pregnancy.
Correct Answer is A
Explanation
Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.
Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.
Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push effectively with her contractions.
Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inflammation in the perineal area.
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