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”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Complete activities with one client before moving to another client: Focusing on only one client at a time can reduce efficiency, especially when tasks can be clustered. Effective time management often involves grouping similar tasks across clients to minimize unnecessary movement and interruptions.
B. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift increases the risk of omissions and inaccuracies. Timely, ongoing documentation throughout the shift supports accuracy and safe continuity of care.
C. Make a priority to-do list at the beginning of the shift: Creating a prioritized task list helps the nurse organize care based on urgency and client needs. This approach improves efficiency and ensures that high-priority interventions are addressed first.
D. Delegation of vital signs to the assistive personnel on the team: Delegating routine tasks such as vital signs allows the nurse to focus on assessments and interventions requiring professional judgment. Appropriate delegation is a key strategy for effective time management.
E. Keep track of how long it takes to complete certain tasks: Monitoring how long tasks take helps the nurse plan more realistically and adjust workflow. This awareness supports better scheduling and improved efficiency over time.
Correct Answer is A
Explanation
A. Wheat bread: Wheat bread is relatively low in potassium compared with fruits, vegetables, and juices. It is generally appropriate for clients who require potassium restriction due to renal disease or certain electrolyte imbalances.
B. Orange juice: Orange juice is high in potassium and can significantly increase serum potassium levels. It is commonly restricted in clients who must limit potassium intake to prevent hyperkalemia.
C. Sweet potato: Sweet potatoes contain a high amount of potassium, especially when baked or mashed. They are typically avoided in low-potassium diets because they can rapidly elevate potassium levels.
D. Canned green beans: Although canned vegetables have less potassium than fresh ones due to processing, green beans still contain more potassium than wheat bread. They are not the lowest potassium option.
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