A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time.
I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

It can be tough adjusting to a new baby.

You shouldn’t be doing any chores.

It’s common to feel worn out for the first 3 months. Try to rest when the baby is sleeping.

It’s normal to feel fatigued for the first few weeks. Be patient with yourself and try to rest more.

None

Answer and Explanation

The Correct Answer is A

Choice A rationale

A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it’s normal for new mothers to feel overwhelmed and fatigued. The nurse’s response should be empathetic and supportive,

encouraging the client to share more about her situation. This could help the nurse understand the client’s support system and provide appropriate advice or resources.

Choice B rationale

While it’s important to ensure that the client isn’t overexerting herself with chores, suggesting that she shouldn’t be doing any at all might not be practical or feasible. The presence and involvement of family members can vary greatly, and while their help can be beneficial, it’s not the only factor in managing postpartum fatigue.

Choice C rationale

It’s indeed common for new mothers to feel worn out for the first few months. However, simply advising the client to rest when the baby is sleeping might not address the root cause of her fatigue. It’s also important to consider other factors such as nutrition, emotional well- being, and available support.

Choice D rationale

Telling the client that it’s normal to feel fatigued for the first few weeks might minimize her feelings. Each person’s postpartum experience is unique, and it’s crucial to validate her feelings and provide individualized care.

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Correct Answer is A

Explanation

Choice A rationale

A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.

Choice B rationale

While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.

Choice C rationale

Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.

Choice D rationale

Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.

A. Administer oxygen via facemask. B. Change the client’s position. C. Turn off the oxytocin infusion. D. Assess cervical dilatation.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.

Choice B rationale

Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.

Choice C rationale

Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.

Choice D rationale

Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.

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A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Correct Answer is A

Explanation

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

Correct Answer is B

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

A postpartum client who is formula-feeding her new baby inquires about when she should expect her menstruation to resume.What should the nurse inform the client?

A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time.
I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?