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.

Answer and Explanation

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.

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Correct Answer is ["0.5"]

Explanation

Step 1 is 400 mg÷ 800 mg/tablet.

Step 2 is 400 ÷ 800 = 0.5. The final calculated answer is 0.5 tablets.

A. Vaginal fluid has a pH of 5.3. B. Nitrazine paper turns yellow. C. Vaginal fluid is negative for ferning. D. Nitrazine paper turns dark blue.

Correct Answer is D

Explanation

Choice A rationale

Normal vaginal fluid is acidic due to the presence of Lactobacillus species, which convert glycogen to lactic acid, maintaining a pH typically between 4.5 and 6.0. Amniotic fluid is alkaline, with a pH usually ranging from 7.0 to 7.5. Therefore, a pH of 5.3 indicates acidic vaginal secretions, suggesting the fluid is likely not amniotic fluid and ruling out premature rupture of membranes (PROM).

Choice B rationale

Nitrazine paper is used to test the pH of vaginal fluid. It is impregnated with a pH-sensitive dye. When the paper comes into contact with acidic fluid (normal vaginal secretions, pH < 6.0), it will remain yellow or turn a yellow-green color. This result indicates an acidic environment, which is inconsistent with the alkaline nature of amniotic fluid (pH≥ 6.5), making PROM unlikely.

Choice C rationale

Ferning refers to the characteristic microscopic crystallization pattern that dried amniotic fluid forms due to its salt and protein content. A negative ferning test means the characteristic pattern is absent. This negative result suggests the fluid is not amniotic fluid, thereby providing evidence against the diagnosis of premature rupture of membranes (PROM).

Choice D rationale

Nitrazine paper turning a dark blue color (or royal blue, deep blue-green, or deep blue) indicates an alkaline pH of 6.5 or greater. Amniotic fluid is alkaline, typically with a pH of 7.0 to 7.5. Therefore, this color change strongly suggests the presence of amniotic fluid, which is the defining diagnostic finding for premature rupture of membranes (PROM).

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer acyclovir 400 mg tablet PO three times per day. Available is 800 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

A nurse is caring for a client who is at 16 weeks of gestation and reports a sudden gush of vaginal fluid. Which of the following findings indicates premature rupture of membranes?

Correct Answer is D

Explanation

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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?