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 A
Explanation
Choice A rationale: The correct term to document this finding is "Quickening." Quickening refers to the first perception of fetal movement by the pregnant woman, usually described as light fluttering or sensation of movement in the abdomen. It is an exciting milestone for pregnant women and often occurs around 18 to 20 weeks of gestation. It is a significant moment as it indicates the woman can feel the baby's movements, signifying the fetus's increasing activity and growth.
Choice B rationale: Ballottement is a physical examination technique used to assess the fetus's position and movement within the amniotic fluid during pregnancy. It involves a gentle tap on the mother's abdomen to feel the fetus bounce or float in the amniotic fluid.
Choice C rationale: Chloasma, also known as the "mask of pregnancy," refers to dark patches of skin that may appear on the face during pregnancy due to hormonal changes. It is not related to the sensation of fetal movement.
Choice D rationale: Lightening, also known as "engagement," is the process in late pregnancy when the baby's head descends into the pelvis, preparing for childbirth. It often occurs a few weeks before labor begins and can result in the mother feeling less pressure on her diaphragm, which may make breathing easier. It is not related to the perception of fetal movement described by the client.
Correct Answer is A
Explanation
Choice A rationale:
A newborn can lose up to 10% of their birth weight in the first few days after birth, which is considered normal. By 7-14 days of age, the baby should have regained their birth weight if breastfeeding effectively.
Choice B rationale:
Gaining 0.25 oz (7 grams) per day after the fourth day of life is not a standard guideline for assessing effective breastfeeding.
Choice C rationale:
Expecting the baby to have less than 5 wet diapers per day after the fourth day of life may indicate dehydration or inadequate breastfeeding, which is not a sign of effective breastfeeding.
Choice D rationale:
Expecting the baby to feed constantly during the first week of life is not necessarily an indicator of effective breastfeeding. While frequent feeding is normal in the early days, the baby should be able to effectively feed and show signs of satiety after nursing.
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