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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Cesarean birth is a factor strongly associated with postpartum deep-vein thrombosis (DVT) After a cesarean section, the risk of developing DVT increases due to reduced mobility and potential trauma to blood vessels during the surgery. Decreased mobility can lead to blood stasis, increasing the risk of clot formation.
Choice B rationale:
Rheumatoid arthritis (Choice B) is not directly associated with an increased risk of postpartum DVT. Other autoimmune disorders, such as antiphospholipid syndrome, may be associated with a higher risk of DVT, but rheumatoid arthritis itself is not a known risk factor.
Choice C rationale:
Hypotension (Choice C) is not directly linked to an increased risk of postpartum DVT. However, hypotension can be associated with other complications and should be managed appropriately.
Choice D rationale:
Uterine atony (Choice D) is excessive bleeding following childbirth due to the uterus not contracting adequately. While it is a postpartum complication, it is not directly associated with an increased risk of DVT.
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.
Choice B reason:
Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.
Choice C reason:
Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.
Choice D reason:
Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.
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