A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication?
- A. Chamomile tea can potentiate the affect of the drug.
- B. Therapeutic effect may be delayed a week or more.
- C. The medication should only be taken whole.
- D. A weight gain of up to ten pounds is commonly seen.
Correct Answer: B
Rationale: Antidepressants require time to take effect.
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Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Facial expression.
Correct Answer: A
Rationale: Heart rate and facial expression are key indicators of neonatal pain.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Instructing the person to call the nurse to warm up food or drink is the best way to support the cultural tradition of consuming warm drinks and food. This option respects the individual's cultural preferences and provides a practical solution to meet their needs without imposing personal opinions. By offering assistance in warming up the food or drink, the nurse acknowledges and honors the person's cultural background, promoting a culturally sensitive and patient-centered approach.
Summary of Incorrect Choices:
A: Explaining that nurses do not have control over the food dismisses the person's request and does not address the cultural tradition.
B: Telling the person that cold fluids are better for recovery disregards the cultural preference for warm drinks and food.
D: Educating the person on culture in the United States is not relevant to supporting their specific cultural tradition of consuming warm drinks and food.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.” How should the nurse best respond?
- A. Reassure him that this behavior is normal.
- B. Advise him to get immediate psychological help for her.
- C. Tell him to ignore the mood swings because they will go away.
- D. Instruct him in the signs, symptoms, and duration of postpartum blues.
Correct Answer: A
Rationale: The correct answer is A. The nurse should reassure the father that his wife's behavior of mood swings is normal after childbirth due to hormonal changes and adjustment to new responsibilities. This response validates the father's concerns, provides education on common postpartum experiences, and offers support.
Incorrect choices:
B: Immediate psychological help is not warranted for typical postpartum mood swings.
C: Ignoring the mood swings can lead to misunderstandings and lack of support for the mother.
D: Instructing on postpartum blues is more clinical and may not address the father's immediate concerns.
The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby?
- A. The baby will have a bath with soap every morning.
- B. During a supervised play period
- C. the baby will be placed on the tummy every day.
- D. The baby will be given a pacifier after each feeding.
Correct Answer: B
Rationale: Tummy time promotes motor development.