A nurse in a clinic is caring for a client who is 4 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down and sad,” having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
Ask the client if she has thoughts of or considered harming herself or her newborn.
Anticipate a prescription by the provider for an antidepressant.
Assist the family to identify prior use of positive coping skills in family crises.
Reinforce postpartum and newborn care discharge teaching.
The Correct Answer is A
Choice A rationale
Asking the client if she has thoughts of or considered harming herself or her newborn is the priority action. This assessment is crucial for identifying postpartum depression and potential risks to the client and her newborn. Early identification and intervention can prevent harm.
Choice B rationale
Anticipating a prescription for an antidepressant is important but secondary to assessing immediate safety concerns. Medication can be part of the treatment plan after assessing the client’s mental state.
Choice C rationale
Assisting the family to identify prior use of positive coping skills is beneficial for long-term management but is not the immediate priority. The nurse must first ensure the client’s and newborn’s safety.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important for overall care but does not address the immediate concern of potential harm due to postpartum depression.
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Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Warm compresses can help to reduce perineal pain and swelling by increasing blood flow to the area, which promotes healing and provides comfort. The warmth can also help to relax the muscles and reduce discomfort.
Choice B rationale
Tucks pads, which contain witch hazel, are effective in reducing perineal pain and swelling. Witch hazel has anti-inflammatory and astringent properties that help to soothe irritated skin and reduce swelling, providing relief from discomfort.
Choice C rationale
Dermaplast spray is a topical anesthetic that provides temporary relief from perineal pain. It contains benzocaine, which numbs the area and reduces pain. It also has antiseptic properties that help to prevent infection in the perineal area.
Choice D rationale
Ibuprofen 600 mg PO is a nonsteroidal anti-inflammatory drug (NSAID) that helps to reduce pain and inflammation. It works by inhibiting the production of prostaglandins, which are chemicals that cause inflammation and pain. Taking ibuprofen can provide significant relief from perineal discomfort.
Choice E rationale
Encouraging the patient to sit in a high Fowler’s position is not recommended for perineal pain management. This position can increase pressure on the perineum, potentially worsening the pain and discomfort.
Correct Answer is D
Explanation
Choice A rationale
Using a bladder scanner to assess for urinary retention is a non-invasive and appropriate intervention. It helps determine the volume of urine in the bladder and can guide further management. This method avoids unnecessary catheterization and reduces the risk of infection.
Choice B rationale
Catheterizing to empty the bladder is a common intervention for urinary retention. However, it should be done with caution and only when necessary to avoid the risk of infection. In this scenario, it is not contraindicated but should be considered after other non-invasive methods have been tried.
Choice C rationale
Placing peppermint oil on a cotton ball and placing it in the urinary “hat” while the client is on the toilet is a non-invasive method that can help stimulate urination through the scent of peppermint. This method is safe and can be effective for some clients.
Choice D rationale
Assisting the client back to bed and telling her to try to void again in 2 hours is contraindicated because it delays the intervention for a distended bladder. A distended bladder can cause discomfort and potential complications, so timely intervention is necessary.