When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse’s primary concern in planning the client’s care?
Harm to herself or her infant.
Displaying outbursts of anger.
Neglecting her hygiene.
Losing trust in her husband.
The Correct Answer is A
Choice A rationale
Postpartum depression with psychotic features may lead to suicidal ideation or infanticidal tendencies due to delusions or hallucinations. Ensuring safety is critical to prevent harm to both mother and infant.
Choice B rationale
Anger outbursts, though concerning, do not pose immediate threats like harm to self or infant. Addressing this behavior is secondary to prioritizing safety in severe postpartum psychosis cases.
Choice C rationale
Neglecting hygiene reflects depressive symptoms but does not indicate psychosis severity or imminent danger. Primary focus remains on managing safety risks to the mother and infant.
Choice D rationale
Losing trust in her husband is relevant to interpersonal stress but does not constitute a primary care concern. The immediate threat of harm takes precedence over marital dynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A soft uterus indicates uterine atony, a complication rather than a normal finding. Daily fundal palpation ensures involution but should result in a firm, not soft, uterus.
Choice B rationale
Passage of clots is common postpartum, but ongoing monitoring for excessive clotting is crucial as it may indicate retained placental fragments or incomplete uterine involution.
Choice C rationale
Decreased lochia does not indicate complications unless it is completely absent, which may suggest uterine or cervical obstruction and warrants further evaluation.
Choice D rationale
Increased lochia or bright red bleeding signifies secondary postpartum hemorrhage, often caused by retained placental tissue or subinvolution, requiring immediate medical attention.
Correct Answer is B
Explanation
Choice A rationale
Surgical intervention is not the initial step for uterine atony as conservative measures, such as fundal massage, are prioritized to encourage uterine contraction and reduce bleeding.
Choice B rationale
Fundal massage stimulates uterine contraction by mechanically compressing the myometrium, which helps to constrict the spiral arteries and reduce hemorrhage caused by uterine atony.
Choice C rationale
Establishing venous access is critical for fluid resuscitation but does not directly address the underlying cause of hemorrhage, which requires mechanical or pharmacological uterine contraction.
Choice D rationale
Catheterizing the bladder can prevent displacement of the uterus but does not directly address uterine atony. An empty bladder supports fundal massage by allowing proper uterine positioning.
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