A nurse massages the uterus of a postpartum woman after making a hypothesis of uterine atony.
Which of the following outcomes would indicate that the client's condition had improved?
Decreased pain level.
Stable blood pressure.
Fundus firm at or below the umbilicus.
Reduced lochial flow.
The Correct Answer is C
Choice A rationale
Decreased pain level can be an effect of addressing the cause of pain, but it doesn't indicate improved uterine tone or resolution of atony.
Choice B rationale
Stable blood pressure is important, but it is not the direct outcome of improved uterine tone or the resolution of uterine atony.
Choice C rationale
A firm fundus at or below the umbilicus indicates successful contraction of the uterus, resolving uterine atony and reducing bleeding.
Choice D rationale
Reduced lochial flow can indicate decreased bleeding, but it does not directly indicate improved uterine tone or resolution of uterine atony.
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Correct Answer is D
Explanation
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis is a serious mental health condition that can result in delusions and hallucinations. These symptoms increase the risk of harm to the infant, so it's essential that
the mother is not left alone with the baby to ensure both their safety.
Choice B rationale
Symptoms of postpartum psychosis typically last longer than one week and require medical intervention, contrary to what is stated in this choice. Treatment usually involves
antipsychotics, mood stabilizers, and sometimes hospitalization.
Choice C rationale
Clinical response to medications can be significant in many cases, and early and aggressive treatment often leads to improvement. This statement is inaccurate and does not reflect
the current understanding of postpartum psychosis treatment.
Choice D rationale
While monitoring vital signs is essential, it is not as critical as ensuring the infant's safety given the mother’s severe mental condition. The focus should be on psychiatric
management and safety protocols rather than routine vitals alone.