The nurse is continuing to care for the client.

Complete the following sentence by using the list of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition.

The action the nurse should take first is

_____

followed by

_____

.

Rationale for correct choices

• Thoughts of self‑harm: The client recently experienced multiple major stressors, loss of a job and the end of a long-term relationship, while displaying flat affect, tearfulness, withdrawal, and refusal to eat. These changes, combined with the statement, “My life is a mess,” indicate worsening depression and internal distress. These findings elevate the risk for self‑harm and require immediate monitoring.

• Hopelessness: The client’s statements reflect feelings of worthlessness and an inability to see a path forward, which are hallmark signs of hopelessness. Their withdrawal, refusal to eat, and persistent tearfulness reinforce that they are overwhelmed and unable to cope with current stressors. Hopelessness is closely linked with suicidal ideation, explaining the elevated self‑harm risk.

Rationale for incorrect choices

• Anorexia nervosa: Although the client is refusing meals, this refusal occurs in the context of emotional distress rather than weight‑loss motivation or body‑image disturbance. The client’s BMI is low but not critically low, and there is no fear of gaining weight or distorted self‑perception. Appetite changes are common in depression and better explained by mood not eating disorders.

• Acute dystonic reaction: Acute dystonia is associated with antipsychotic medications, not sertraline, which the client is currently taking. No signs such as muscle spasms, stiff neck, or oculogyric crisis are present. The client’s symptoms are emotional and cognitive, not neuromuscular.

• Refusal to eat: While refusal to eat is concerning, it alone does not most strongly indicate risk for self‑harm. Poor appetite is common in depression and may reflect low motivation or energy. It lacks the direct emotional connotation that hopelessness carries in predicting self‑harm.

• Family history: A family history of major depressive disorder increases long‑term vulnerability but does not explain the client’s immediate risk situation. The client’s current behaviors and statements provide more immediate clinical evidence than hereditary factors. Family history does not sufficiently reflect the acute emotional state contributing to self‑harm risk.

A. Heart rate 190/min: A normal newborn heart rate ranges from 120 to 160 beats per minute. A heart rate of 190/min is tachycardic and is above the expected range for a healthy newborn.

B. Irregular respirations: Newborns often exhibit irregular respirations with periods of rapid breathing followed by pauses. This pattern is expected in the first few hours after birth and usually does not indicate distress if oxygen saturation is normal.

C. Central cyanosis: Central cyanosis, including blue lips or tongue, is abnormal and may indicate hypoxemia or congenital heart or respiratory issues. Normal newborns may show brief acrocyanosis of hands and feet but not central cyanosis.

D. Temperature of 38.2° C (100.8° F): A normal newborn temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F). A temperature of 38.2° C is elevated and may indicate infection or overheating.