A nurse is assessing a client who gave birth 1 week ago. The client states, "I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.” The nurse should identify that the client is experiencing which of the following emotional responses to birth?
Postpartum depression.
Taking-in phase.
Postpartum blues.
Taking-hold phase.
The Correct Answer is C
Choice A rationale:
Postpartum depression is a more severe and prolonged form of emotional response to childbirth. It involves persistent feelings of sadness, hopelessness, and difficulty bonding with the baby. The symptoms of postpartum depression are different from what the client is experiencing, so this choice is not correct.
Choice B rationale:
The taking-in phase is a normal emotional response to birth, where the mother is focused on her own needs and experiences during the immediate postpartum period. The client's symptoms do not align with this phase, as she is expressing feelings of sadness and crying for no reason.
Choice C rationale:
The postpartum blues, also known as the "baby blues,” is the correct choice. It is a common and transient emotional response to birth experienced by many new mothers. The mother may feel overwhelmed, have mood swings, and cry for no apparent reason. These symptoms usually resolve on their own within a few days to a couple of weeks, and supportive care is typically sufficient.
Choice D rationale:
The taking-hold phase is a phase where the mother becomes more confident in her caregiving abilities and starts to take a more active role in caring for her baby. The client's symptoms do not align with this phase, as she is expressing feelings of sadness and crying for no reason.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
Correct Answer is D
Explanation
Choice A reason:
Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.
Choice B reason:
Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.
Choice C reason:
Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.
Choice D reason:
Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat
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