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Client gave birth 1 week ago, states: 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.'
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
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Client who is Rh-negative.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.
Client with a prescription for ibuprofen to treat postpartum cramping.
A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication?
- A. Are you taking over-the-counter medications?
- B. Do you have a history of gastric problems?
- C. What kind of contraception will you be using?
- D. Are you being treated for high blood pressure?
Correct Answer: A
Rationale: Ibuprofen can interact with various over-the-counter medications, including anticoagulants and corticosteroids, which may increase risks of side effects like gastrointestinal bleeding or reduced efficacy, necessitating careful assessment of concurrent drug use.
Newborn whose mother had gestational diabetes mellitus.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Jitteriness.
- B. Hypertonia.
- C. Acrocyanosis of the hands.
- D. Generalized petechiae.
Correct Answer: A
Rationale: Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.
Client at 33 weeks of gestation with preeclampsia.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
- A. BUN level of 30 mg/dL (normal range: 10 to 20 mg/dL).
- B. Hemoglobin level of 9.9 g/dL (normal range: 11 to 16 g/dL).
- C. Serum uric acid level of 2.5 mg/dL (normal range: 2.7 to 7.3 mg/dL).
- D. Casual blood glucose level of 228 mg/dL (normal range: less than 200 mg/dL).
Correct Answer: A
Rationale: A BUN level of 30 mg/dL is above the normal range of 10 to 20 mg/dL. Elevated BUN is consistent with renal involvement in preeclampsia, which is caused by vascular constriction and reduced renal perfusion.
Client has been pushing for 2.5 hours with minimal progress, fetal head remains at +2 station.
A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.