A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry.

Which of the following is a priority action by the nurse?

Assist the family to identify prior use of positive coping skills in family crises.

Ask the client if she has considered harming her newborn.

Anticipate a prescription by the provider for an antidepressant.

Reinforce postpartum and newborn care discharge teaching.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.

Choice B rationale:

This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.

Choice C rationale:

Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.

Choice D rationale:

Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.

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Correct Answer is A

Explanation

Choice A rationale:

Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.

Choice B rationale:

This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.

Choice C rationale:

This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.

Choice D rationale:

This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.

A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

Correct Answer is A

Explanation

Choice A rationale:

Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.

Choice B rationale:

Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.

Choice C rationale:

This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.

Choice D rationale:

This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.

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A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant client's last menstrual period was May 4th, 2018. What is this client's estimated delivery date using Naegele's Rule?

Correct Answer is A

Explanation

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is A

Explanation

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A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry.

Which of the following is a priority action by the nurse?