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 Moro reflex, also known as the startle reflex, is elicited by making a loud noise or performing a sharp hand clap near the newborn. In response to the stimulus, the newborn will throw their arms and legs outward and then bring them back toward the center of the body.
Choice B rationale: Placing a finger at the base of the newborn's toes is not related to eliciting the Moro reflex. This action may elicit the Babinski reflex, which causes the toes to fan out and the big toe to dorsiflex.
Choice C rationale: This action may elicit the stepping reflex, where the newborn will make stepping movements when the soles of their feet touch a flat surface. It is not related to eliciting the Moro reflex.
Choice D rationale: Turning the newborn's head quickly to one side is not related to eliciting the Moro reflex. This action may elicit the asymmetric tonic neck reflex (ATNR), where the newborn will extend the arm and leg on the side their head is turned to and flex the opposite arm and leg.
Correct Answer is B
Explanation
Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.
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