A nurse is collecting data from a client who is 48 hr postpartum.
Which of the following findings reported by the client should the nurse identify as a postpartum psychosocial concern?
The newborn reminds the client of themself as a newborn.
The client reports fatigue and a desire to sleep.
The client does not want to feed the newborn.
The client discusses a desire to have more children.
The Correct Answer is C
Choice A rationale
Relating the newborn to oneself is a normal process during the "taking-hold" phase of maternal role attainment, typically occurring 2-10 days postpartum, where the mother focuses on the infant and parental role. This involves identifying the newborn as a separate individual while making comparisons, which is an expected psychosocial milestone and not indicative of a concern.
Choice B rationale
Postpartum fatigue and a desire to sleep are common physiological and psychological responses due to the physical exertion of labor, blood loss (normal postpartum blood loss is ≤ 500 mL for vaginal delivery), and interrupted sleep patterns. This is an expected finding and reflects the body's need for rest and recovery, not a pathological psychosocial concern within 48 hours.
Choice C rationale
The absence of desire to feed the newborn or a lack of interest in the infant can be an early indicator of postpartum blues or a more severe mood disorder like postpartum depression. Postpartum blues peaks around day five and resolves within two weeks, but a strong disinterest requires further assessment as it affects bonding and infant care.
Choice D rationale
Discussing the desire for future children indicates a healthy anticipation of a continued family life and is a sign of good adjustment and optimism regarding the maternal role and relationship. This finding is reassuring and signifies positive psychological adaptation rather than a postpartum psychosocial concern within this early timeframe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The proper sequence for suctioning a newborn is the mouth first, then the nose, to prevent the newborn from aspirating secretions. Suctioning the nose first may cause the newborn to gasp, drawing pharyngeal secretions into the trachea and lungs, potentially leading to aspiration pneumonia or respiratory distress.
Choice B rationale
Depressing the bulb prior to insertion into the mouth or nose creates a negative pressure inside the bulb. Releasing the pressure after insertion will then effectively draw secretions into the bulb, achieving optimal suction. Inserting a non-depressed bulb will be ineffective for removing secretions.
Choice C rationale
The bulb syringe does not require lubrication with sterile water before use; it is intended for immediate use as a mechanical suction device. Lubrication could potentially introduce excess fluid into the newborn's airway or dilute secretions, which does not enhance the device's primary function of removing mucus.
Choice D rationale
The bulb should be placed gently into the sides of the newborn's mouth, rather than the center, to avoid stimulating the gag reflex. Placing it at the sides directs suction toward the cheeks and gums, facilitating the removal of secretions from the oral cavity without causing discomfort or vomiting.
Correct Answer is D
Explanation
Choice A rationale
Calcium is essential for fetal bone and tooth development, as well as for maternal skeletal integrity, muscle function, and blood clotting. Although crucial, an increase in calcium intake (normal recommended intake is 1000 mg/day for most pregnant women) is primarily aimed at skeletal and cellular health, not specifically at the physiological increase in maternal blood volume, which necessitates increased erythrocyte production and plasma volume.
Choice B rationale
Vitamin E is an important fat-soluble antioxidant that protects cell membranes from oxidative damage and plays a role in red blood cell (RBC) integrity. While it is necessary for overall maternal and fetal health, its primary function is not directly linked to the significant expansion of maternal plasma and erythrocyte mass, which is the physiological basis for the approximately 30% to 50% increase in maternal blood volume during pregnancy.
Choice C rationale
Vitamin D is a fat-soluble vitamin critical for intestinal absorption of calcium and phosphorus, thereby maintaining optimal bone mineralization and immune function. Although supplementation is often necessary, especially in those with limited sun exposure (normal range 20-50 ng/mL), its primary role is in calcium homeostasis and immune function, not as a direct substrate for the substantial increase in maternal plasma volume and red blood cell mass during gestation.
Choice D rationale
Iron is a fundamental component of the heme group in hemoglobin, which is crucial for oxygen transport by red blood cells (RBCs). The approximately 45% increase in maternal blood volume during pregnancy requires a substantial increase in RBC production (erythropoiesis) to prevent dilutional anemia. Therefore, increased iron intake (normal recommended intake 27 mg/day) is vital for the necessary synthesis of hemoglobin to support this physiologic increase in maternal erythrocyte volume.
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