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:
Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.
Choice B rationale:
Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.
Choice C rationale:
A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.
Choice D rationale:
Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
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