A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry.

Which of the following is a priority action by the nurse?

Assist the family to identify prior use of positive coping skills in family crises.

Ask the client if she has considered harming her newborn.

Anticipate a prescription by the provider for an antidepressant.

Reinforce postpartum and newborn care discharge teaching.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.

Choice B rationale:

This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.

Choice C rationale:

Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.

Choice D rationale:

Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.

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Correct Answer is D

Explanation

Choice A rationale:

Leaving the diaphragm in place for 4 hours following intercourse is incorrect. The diaphragm should be left in place for at least 6 hours after intercourse to ensure effectiveness in preventing pregnancy.

Choice B rationale:

Removing the diaphragm by catching the rim below the dome with the forefinger is incorrect. The diaphragm should be removed by hooking the finger behind the rim to avoid damaging the dome and ensure proper removal.

Choice C rationale:

Placing a thin layer of mineral oil on the diaphragm once per week is incorrect. Mineral oil can weaken latex diaphragms, reducing their effectiveness. Water-based lubricants are recommended for use with diaphragms.

Choice D rationale:

Placing 2 teaspoons of spermicide on the inside of the diaphragm before insertion is the correct technique. Spermicide helps to immobilize and kill sperm, enhancing the contraceptive effect of the diaphragm.

A. Both breasts have many nodules in the upper outer quadrants. B. The client states she has bilateral breast tenderness with palpation. C. The left breast is slightly larger than the right breast. D. An irregularly shaped, nontender lump is palpable in the right breast.

Correct Answer is D

Explanation

Choice A rationale:

Having many nodules in the upper outer quadrants of the breasts is a common and expected finding in breast tissue and is not necessarily a cause for concern.

Choice B rationale:

Bilateral breast tenderness with palpation can be a normal finding, especially in young women with hormonal changes. It is not of immediate concern unless it is accompanied by other worrisome symptoms.

Choice C rationale:

Slight differences in breast size are often normal and not necessarily concerning, especially in young women whose breast development may not have fully stabilized.

Choice D rationale:

An irregularly shaped, nontender lump palpable in the breast raises concerns for a potential breast mass or tumor. This finding requires further evaluation and investigation by a healthcare provider to determine its nature and possible malignancy. Early detection of breast abnormalities is crucial for timely management and improved outcomes.

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A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

Correct Answer is D

Explanation

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A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry.

Which of the following is a priority action by the nurse?