A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

“I am so relieved the baby looks like my mother."

"My appetite has really increased."

"My labor was so long. I'm glad it's over."

"I really wish I had a girl instead”

Answer and Explanation

The Correct Answer is D

A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.

B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.

C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.

D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.

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Correct Answer is D

Explanation

A. Decreased hemoglobin level: A reduction in hemoglobin is not an expected effect of furosemide and may indicate anemia or another unrelated condition. It does not reflect the diuretic’s effectiveness in managing fluid overload.

B. Increased weight of 0.91 kg (2 lb): An increase in weight suggests fluid retention rather than loss. Effective furosemide therapy should result in stable or decreased weight as excess fluid is excreted. Monitoring weight helps assess fluid balance in heart failure patients.

C. Decreased BUN level: Changes in BUN are influenced by multiple factors including renal function, hydration, and protein intake. A decrease is not a reliable indicator of furosemide effectiveness in reducing fluid volume.

D. Increased urinary output: Furosemide is a loop diuretic that promotes excretion of sodium and water. An increase in urinary output indicates that the medication is effectively removing excess fluid, reducing edema, and alleviating symptoms of heart failure.

A. An assistive personnel is encouraging intake of oral fluids. B. Supplemental oxygen is in use. C. Benzodiazepines are administered every 4 hr. D. A family member remains at the client's bedside 24 hr each day.

Correct Answer is A

Explanation

A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.

B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.

C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.

D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.

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A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

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