Choice A rationale

Delusions indicate severe psychiatric conditions like postpartum psychosis, not depression. Depression involves low mood, energy, and interest, without detachment from reality. Delusions reflect loss of reality testing, requiring different interventions. Common in severe psychoses like schizophrenia.

Choice B rationale

Euphoria indicates abnormally elevated mood, seen in manic episodes of bipolar disorder, not depression. Depression involves sadness, hopelessness, and low energy. Euphoria's excessive positivity contrasts with depressive symptoms, including impaired functioning and behavior regulation.

Choice C rationale

Flat affect signifies reduced emotional expression, common in depression. Depressed individuals exhibit lack of response to pleasurable activities, social withdrawal, and emotional blunting. This impairment in emotional expressiveness reflects major depressive disorder.

Choice D rationale

Insomnia, common in depression, affects sleep patterns, causing difficulty initiating or maintaining sleep. It contributes to fatigue, cognitive impairment, and mood disturbances. Insomnia reflects dysregulated sleep-wake cycles in depression, impacting daily functioning.

Choice E rationale

Fatigue is frequent in depression, marked by persistent tiredness despite rest. It stems from sleep disturbances, low energy, and anhedonia. Fatigue affects concentration, motivation, and physical activity, manifesting as psychomotor retardation in depression.

Choice A rationale

Decrease proteinuria is not the primary goal for magnesium sulfate therapy. It's an indicator of kidney function and hypertension severity. Therapy focuses on neuroprotection and seizure prevention. Proteinuria reflects preeclampsia's renal impact, not neuroprotection.

Choice B rationale

Prevent maternal seizures is magnesium sulfate's primary goal. It stabilizes neuronal membranes, reducing seizure risk in severe preeclampsia. By inhibiting NMDA receptors and calcium channels, it prevents seizures, critical for maternal-fetal safety.

Choice C rationale

Reduce deep tendon reflexes is not magnesium sulfate's primary goal, but a side effect. It signifies therapeutic levels, indicating potential toxicity. Reflex reduction helps assess magnesium toxicity risk, ensuring safe neuroprotective dosing.

Choice A rationale

While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.

Choice B rationale

Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.

Choice C rationale

Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.

Choice D rationale

Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.

Choice A rationale

Checking basal temperature during specific days of the menstrual cycle does not provide as accurate an indication of ovulation as consistent daily measurements.

Choice B rationale

Checking temperature before bed may not accurately reflect basal body temperature due to daily activities affecting body temperature.

Choice C rationale

Basal body temperature should be measured every morning before arising, as this reflects the body’s lowest resting temperature and helps identify ovulation.

Choice D rationale

Checking temperature after intercourse may be affected by physical activity and does not provide an accurate basal temperature reading for ovulation tracking.

Choice A rationale

Bruising on the head is common in newborns after a precipitous delivery due to rapid passage through the birth canal, causing trauma to the head.

Choice B rationale

Low birth weight is not specifically associated with precipitous delivery but could be related to other prenatal factors affecting fetal growth.

Choice C rationale

Hypotonia is not a typical finding in a newborn after a precipitous delivery, though it could indicate other neurological or muscular issues.

Choice D rationale

Hyperthermia is not a common finding directly associated with precipitous delivery but could be related to other factors or conditions in the newborn.

Choice A rationale

Severe nausea and vomiting are not specific symptoms of a ruptured ectopic pregnancy but may occur due to other unrelated conditions.

Choice B rationale

Bradycardia is not characteristic of a ruptured ectopic pregnancy but could indicate other cardiovascular issues or conditions.

Choice C rationale

Referred shoulder pain is a hallmark symptom of a ruptured ectopic pregnancy due to diaphragmatic irritation from internal bleeding, indicating potential rupture.

Choice D rationale

Heavy vaginal bleeding can occur in various conditions but is not as specific to ruptured ectopic pregnancy as referred shoulder pain indicating internal bleeding.

Choice A rationale

Amniotic fluid embolism is characterized by the sudden onset of respiratory distress due to the entry of amniotic fluid into the maternal circulation.

Choice B rationale

Maternal bradycardia is not a specific symptom of amniotic fluid embolism and may be related to other cardiovascular conditions.

Choice C rationale

Category 1 fetal heart tracing indicates normal fetal heart rate and is not associated with amniotic fluid embolism.

Choice D rationale

Acute, continuous abdominal pain could indicate other obstetric emergencies but is not specifically linked to amniotic fluid embolism symptoms like respiratory distress.

Choice A rationale

Explaining that the newborn is no longer in pain may not facilitate grieving, as it does not acknowledge the emotional connection and grief the parents are experiencing.

Choice B rationale

Sharing the nurse's own experiences and feelings may shift the focus away from the client's emotions, potentially hindering their grieving process.

Choice C rationale

Avoiding calling the newborn by their name can create a sense of detachment and may prevent the client from fully processing their grief.

Choice D rationale

Allowing the client to hold or be with their newborn provides a tangible connection, facilitating the grieving process and helping them come to terms with their loss.

Choice A rationale

Azithromycin is an antibiotic used to treat infections and is not indicated for promoting lung maturity in preterm infants.

Choice B rationale

Indomethacin is a tocolytic agent used to delay preterm labor but does not promote lung maturity in the fetus.

Choice C rationale

Magnesium sulfate is used for neuroprotection and to prevent seizures in preeclampsia, but it does not enhance lung maturity.

Choice D rationale

Betamethasone is a corticosteroid that accelerates fetal lung development and surfactant production, promoting lung maturity in preterm infants.

Choice A rationale

Rh (D) immunoglobulin does not destroy Rh antibodies in newborns; it prevents maternal immune response.

Choice B rationale

Rh (D) immunoglobulin does not damage Rh antibodies in Rh-negative mothers; it prevents antibody formation.

Choice C rationale

Rh (D) immunoglobulin does not stop Rh antibody formation in Rh-positive newborns but prevents it in Rh-negative mothers.

Choice D rationale

Rh (D) immunoglobulin prevents the formation of Rh antibodies in Rh-negative mothers, reducing the risk of hemolytic disease in future pregnancies.