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","E"]
Explanation
Choice A rationale:
Nulliparity (never having given birth) is a known risk factor for ovarian cancer. Women who have never had children have a higher risk compared to those who have. This is believed to be associated with the number of ovulatory cycles a woman experiences throughout her lifetime.
Choice B rationale:
History of breastfeeding does not have a direct link to ovarian cancer risk. In fact, breastfeeding is associated with a reduced risk of both breast and ovarian cancer due to hormonal changes that occur during lactation.
Choice C rationale:
Previous use of oral contraceptives is associated with a decreased risk of ovarian cancer. Women who have used birth control pills have a lower risk compared to those who have never used them. The protective effect is believed to be due to the suppression of ovulation.
Choice D rationale:
History of breast cancer is not a risk factor for ovarian cancer. Although both cancers are related to the reproductive system, they have distinct risk factors and characteristics.
Choice E rationale:
Hormone replacement therapy (HRT) is a potential risk factor for ovarian cancer, especially long-term use. The hormones used in HRT can affect hormone levels and may increase the risk of ovarian cancer.
Correct Answer is B
Explanation
Choice A rationale:
Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.
Choice B rationale:
Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.
Choice C rationale:
Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.
Choice D rationale:
Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.
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