A new mom delivered her baby 2 months ago.
The baby's father calls into the office to report that his wife is angry.
She is confused and having conversations with herself.
What is the appropriate response that the nurse should make?
Please take your wife to the nearest emergency room for evaluation.
Please bring your wife to the office for medication.
Your wife needs outpatient care.
Your wife needs behavioral therapy.
The Correct Answer is A
Choice A rationale:
Advising the caller to take his wife to the nearest emergency room for evaluation is the appropriate response. The new mom's symptoms, including confusion and auditory hallucinations (conversations with herself), are indicative of a serious mental health condition. These symptoms could be caused by postpartum psychosis, a rare but severe form of postpartum depression. Postpartum psychosis requires immediate medical attention and hospitalization for the safety of both the mother and the baby. It is essential to rule out any potential medical causes and provide appropriate psychiatric evaluation and treatment in an emergency setting.
Choice B rationale:
Bringing the wife to the office for medication is not appropriate in this situation. The symptoms described by the baby's father are severe and require urgent evaluation in an emergency room. Medication management should only be initiated after a comprehensive psychiatric evaluation, which can be conducted in an emergency room setting.
Choice C rationale:
Suggesting outpatient care is not appropriate in this case. The severity of the symptoms, including confusion and hallucinations, indicates the need for immediate evaluation in an emergency setting. Outpatient care is not sufficient for addressing acute psychiatric emergencies.
Choice D rationale:
Recommending behavioral therapy is not appropriate for a situation involving acute confusion and hallucinations. Behavioral therapy is a valuable treatment for various mental health conditions, but it is not the appropriate intervention for acute symptoms like those described in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pulmonary stenosis is characterized by a systolic ejection murmur best heard at the upper left sternal border. It does not typically produce a continuous machinery-like murmur. Pulmonary stenosis results from narrowing at the pulmonary valve, obstructing blood flow from the right ventricle to the pulmonary artery.
Choice B rationale:
A continuous machinery-like murmur is characteristic of patent ductus arteriosus (PDA). PDA is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that should close after birth, remains open, allowing continuous blood flow between the aorta and pulmonary artery. This murmur is often best heard in the left infraclavicular region.
Choice C rationale:
Ventricular septal defect (VSD) typically produces a harsh holosystolic murmur heard best at the lower left sternal border. VSD is a hole in the septum separating the ventricles, allowing blood to flow from the higher-pressure left ventricle to the lower-pressure right ventricle.
Choice D rationale:
Coarctation of the aorta causes a murmur due to increased blood flow across the aortic valve. However, this murmur is not continuous and is usually systolic and best heard in the back over the left scapula.
Correct Answer is B
Explanation
The correct answer is choiceb. Fetal movement palpated by the nurse-midwife.
Choice A rationale:
A positive pregnancy test is considered a probable sign of pregnancy, not a positive sign. Probable signs are those that strongly suggest pregnancy but are not definitive.
Choice B rationale:
Fetal movement palpated by the nurse-midwife is a positive sign of pregnancy. Positive signs are those that provide definitive evidence of pregnancy, such as fetal heart tones heard by a Doppler device or ultrasound visualization of the fetus.
Choice C rationale:
Braxton Hicks contractions are considered a probable sign of pregnancy. These are irregular, painless contractions that can occur throughout pregnancy but do not confirm pregnancy definitively.
Choice D rationale:
Quickening, or the first feeling of fetal movement by the mother, is a presumptive sign of pregnancy. Presumptive signs are those that the woman experiences and reports, which may suggest pregnancy but are not conclusive.
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