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
Explanation
Choice A rationale
Galactopoiesis is the process of lactation maintenance and is reliant on breast stimulation and milk removal. This stage involves the ongoing production of milk in response to the infant’s demand.
Choice B rationale
Lactogenesis II refers to the onset of copious milk secretion that occurs around 2-3 days postpartum. It is triggered by the withdrawal of progesterone following the delivery of the placenta.
Choice C rationale
Mammogenesis is the development of the mammary glands during pregnancy. It involves the growth and differentiation of the breast tissue in preparation for lactation.
Choice D rationale
Lactogenesis I refers to the initial stage of milk production that begins during pregnancy and continues through the early postpartum period. It is hormonally driven and prepares the breasts for lactation. .
Correct Answer is D
Explanation
Choice A rationale
Swelling in both breasts is more indicative of engorgement rather than mastitis. Mastitis typically affects only one breast.
Choice B rationale
A white patch on a nipple is more likely a sign of a yeast infection (thrush) rather than mastitis.
Choice C rationale
Cracked and bleeding nipples can be a risk factor for mastitis but are not a definitive sign of the condition.
Choice D rationale
A red and painful area in one breast is a classic sign of mastitis. This condition is often accompanied by flu-like symptoms such as fever and malaise.