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 C
Explanation
Choice A rationale
Encouraging the client to empty her bladder is a common practice to prevent uterine atony and excessive bleeding. However, in this scenario, the fundus is already midline and firm at the umbilicus, indicating that the uterus is well-contracted. Therefore, this action is not necessary.
Choice B rationale
Notifying the client’s provider is not required in this situation. The findings of a light amount of lochia rubra and a firm, midline fundus are normal for 6 hours postpartum. There are no signs of complications that would necessitate contacting the provider.
Choice C rationale
Documenting the findings and continuing to monitor the client is the appropriate action. The client’s condition is stable, and the findings are within the expected range for 6 hours postpartum. Ongoing monitoring will ensure that any changes in the client’s condition are promptly addressed.
Choice D rationale
Increasing the frequency of fundal massage is not needed in this case. The fundus is already firm and midline, indicating that the uterus is well-contracted. Excessive fundal massage can cause discomfort and is unnecessary when the uterus is already in a good position.
Correct Answer is D
Explanation
Choice A rationale
Increasing fluid intake to 2-3 L/day is recommended to prevent dehydration and promote overall health. Adequate hydration can also help soften stools and prevent constipation.
Choice B rationale
Stool softeners are often recommended for postpartum clients, especially those with perineal trauma, to ease bowel movements and prevent straining. They help soften the stool, making it easier to pass without causing additional pain or injury.
Choice C rationale
Increasing fiber intake is beneficial for preventing constipation. High-fiber foods, such as fruits, vegetables, and whole grains, add bulk to the stool and promote regular bowel movements.
Choice D rationale
Rectal suppositories are contraindicated for clients with a fourth-degree laceration. Inserting a suppository can cause trauma to the perineal area and increase the risk of infection or further injury. Alternative methods to manage constipation should be considered.