A nurse is caring for a client who is 2 weeks postpartum. The client tells the nurse, "I feel really down and sad lately. I have no energy and I feel like I'm going to cry." Which of the following actions should the nurse take first?
Reinforce teaching about ways to increase rest and sleep.
Arrange for counseling to help the client cope with the stress of being a parent.
Request a prescription for antidepressant medication.
Use a postpartum depression screening tool with the client.
The Correct Answer is D
Choice A rationale: While adequate rest and sleep are essential postpartum, the client's symptoms of feeling down and sad may be indicative of postpartum depression and should be further evaluated.
Choice B rationale: Counseling may be helpful, but the priority is to first assess and screen for postpartum depression before making additional recommendations.
Choice C rationale: While antidepressant medications might be necessary for postpartum depression, the initial step should be to assess and screen for depression using the appropriate tool.
Choice D rationale: The client's statement and symptoms raise concerns about possible postpartum depression. Using a postpartum depression screening tool will help the nurse assess the severity of the client's symptoms and determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.
Correct Answer is B
Explanation
Choice A rationale: Pain above the navel is not a specific indicator of labor and may be unrelated to the onset of labor.
Choice B rationale: Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening to allow the baby's passage through the birth canal.
Choice C rationale: The presence of amniotic fluid in the vaginal vault (rupture of membranes) could indicate that the client's water has broken, but it does not confirm active labor. Labor can begin before or after the rupture of membranes.
Choice D rationale: Regular contractions are a typical sign of labor, but their frequency alone does not confirm active labor. Other signs, such as cervical dilation and effacement, are necessary to confirm active labor.
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