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 D

Explanation

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

A. "Increase potassium intake.” B. "Increase fluid intake to 3 liters per day.” C. "Decrease sodium intake before menstruation.” D. "Decrease daily fiber intake.”

Correct Answer is C

Explanation

Choice A rationale:

Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.

Choice B rationale:

Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.

Choice C rationale:

Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.

Choice D rationale:

Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.

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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 nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

Correct Answer is C

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?