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?
Arrange for counseling to help the client cope with the stress of being a parent.
Request a prescription for an antidepressant medication.
Reinforce teaching about ways to increase rest and sleep.
Use a postpartum depression-screening tool with the client.
The Correct Answer is D
The correct answer is choice d. Use a postpartum depression-screening tool with the client.
Choice A rationale:
Arranging for counseling is important for long-term support, but the first step is to accurately assess the client’s condition using a screening tool.
Choice B rationale:
Requesting a prescription for an antidepressant may be necessary, but it should follow a proper assessment and diagnosis.
Choice C rationale:
Reinforcing teaching about rest and sleep is beneficial, but it does not address the immediate need to assess the severity of the client’s symptoms.
Choice D rationale:
Using a postpartum depression-screening tool is the first step to identify 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","D","E"]
Explanation
Choice C rationale:
The client's blood pressure of 170/101 mm Hg is significantly elevated. This is a systolic blood pressure above 160 mm Hg and a diastolic blood pressure above 110 mm Hg, which is indicative of severe hypertension. Elevated blood pressure during pregnancy can be a sign of preeclampsia, a condition that can have serious consequences for both the mother and the fetus. Therefore, the nurse should report this finding to the provider immediately. Choice C is the correct answer.
Choice D rationale:
Visual disturbances, such as blurred vision, can be an early symptom of preeclampsia. These symptoms, in combination with the elevated blood pressure, are concerning and should be reported to the provider promptly. Visual disturbances can be a sign of central nervous system involvement in preeclampsia. Choice D is the correct answer.
Choice E rationale:
Blood pressure is a vital sign that should be closely monitored during pregnancy. The elevated blood pressure of 170/101 mm Hg is a critical finding and should be reported to the provider immediately. Elevated blood pressure is one of the key diagnostic criteria for preeclampsia. Choice E is the correct answer.
Choice A rationale:
While changes in respiratory rate can be significant, they are not the primary concern in this scenario. The more pressing issues are the elevated blood pressure and visual disturbances, which are strongly indicative of preeclampsia. Choice A is not the most critical finding in this case.
Choice B rationale:
Fetal heart rate (FHR) of 148 is within the normal range for a fetus. FHR monitoring is important, but in this case, the mother's condition and vital signs take precedence due to the potential risks associated with preeclampsia. Choice B is not the most critical finding in this situation.
Choice F rationale:
Deep tendon reflexes are reported as 3+, which can be a sign of hyperreflexia, a neurological symptom associated with preeclampsia. However, the most immediate concerns in this case are the elevated blood pressure, visual disturbances, and signs of preeclampsia. Choice F is not the most critical finding in this context.
Correct Answer is A
Explanation
Choice A rationale:
Maternal hypertension is the most common risk factor for placental abruption. Placental abruption is a serious condition where the placenta partially or completely separates from the uterine wall before the baby is born. This separation can lead to significant bleeding, which is a medical emergency. Hypertension, also known as high blood pressure, can cause damage to the blood vessels in the placenta, making it more likely for placental abruption to occur. High blood pressure can lead to decreased blood flow to the placenta, increasing the risk of separation.
Choice B rationale:
Maternal battering, while a concerning issue during pregnancy, is not the most common risk factor for placental abruption. Placental abruption is primarily associated with maternal medical conditions and factors that affect the uterine environment.
Choice C rationale:
Maternal cigarette smoking can have adverse effects on pregnancy, but it is not the most common risk factor for placental abruption. Smoking is more commonly associated with other complications such as low birth weight and preterm birth.
Choice D rationale:
Maternal cocaine use is a risk factor for placental abruption, but it is not the most common one. Cocaine can constrict blood vessels and reduce blood flow to the placenta, increasing the risk of abruption. However, hypertension remains the most prevalent risk factor.
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