A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?
"I really wish I had a girl instead."
"I am so relieved the baby looks like my mother."
"My labor was so long I'm glad it's over."
"My appetite has really increased”
The Correct Answer is A
A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.
B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.
C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.
D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "We will switch our baby's car seat to forward-facing when they turn one.": Current guidelines recommend keeping infants and toddlers in a rear-facing car seat until they reach the maximum height or weight limit of the seat, often well past one year, to provide optimal protection in a crash.
B. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": This statement shows good understanding. Car seat surfaces can become dangerously hot and cause burns. Checking the seat temperature ensures the baby’s safety and comfort before securing them inside.
C. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in rear-facing car seats. Car seats should always be placed in the back seat, and airbags should be deactivated if absolutely necessary to place a seat in the front, which is discouraged.
D. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent the harness from fitting snugly and securely. Instead, the harness should be fastened correctly first, and then a blanket can be placed over the baby for warmth.
Correct Answer is C
Explanation
A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.
B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.
C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.
D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.
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