A nurse is collecting data from a client who is 6 weeks postpartum. The client tells the nurse, "I am not a good mother. My baby doesn't like me.” Which of the following actions should the nurse take?
Advise the client that most new mothers experience these feelings.
Ask the client if they have had thoughts about harming their infant.
Explain to the client they are experiencing the "baby blues.”
Take the client to the emergency department.
The Correct Answer is B
Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.
Choice A reason:
The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.
Choice C reason:
The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.
Choice D reason:
Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.
Choice B reason:
Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.
Choice C reason:
Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.
Choice D reason:
Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.
Correct Answer is B
Explanation
Choice A reason:
The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.
Choice B reason:
This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.
Choice C reason:
The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.
Choice D reason:
Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.
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