A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

“I am so relieved the baby looks like my mother."

"My appetite has really increased."

"My labor was so long. I'm glad it's over."

"I really wish I had a girl instead”

Answer and Explanation

The Correct Answer is D

A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.

B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.

C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.

D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.

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Correct Answer is B

Explanation

A. Reduced anxiety: While anxiety may improve with overall health stabilization, it is not a direct indicator of potassium replacement effectiveness. Potassium primarily affects neuromuscular and cardiac function rather than emotional state.

B. Normal sinus rhythm: Hypokalemia can cause cardiac arrhythmias. The presence of a normal sinus rhythm indicates that potassium levels have been corrected and the heart’s electrical activity is stabilized, reflecting a positive response to supplementation.

C. Decreased urinary output: Changes in urinary output are not a direct measure of potassium replacement effectiveness and may indicate other complications, such as renal impairment or fluid imbalance.

D. Decreased blood pressure: Blood pressure changes are not a direct outcome of potassium supplementation and could suggest unrelated cardiovascular issues. Normalization of cardiac rhythm is a more specific indicator of intervention success.

A. Rise slowly from a sitting position to a standing position. B. Decrease daily fluid intake. C. Increase dietary potassium. D. withhold the medication if pulse rate is less than 60/min.

Correct Answer is A

Explanation

A. Rise slowly from a sitting position to a standing position: Enalapril, an ACE inhibitor, can cause orthostatic hypotension, especially when therapy is initiated. Advising the client to rise slowly helps prevent dizziness and syncope related to sudden blood pressure drops.

B. Decrease daily fluid intake: Reducing fluid intake can worsen hypotension and dehydration, increasing the risk of syncope. Maintaining adequate hydration is important unless otherwise instructed by the provider.

C. Increase dietary potassium: While ACE inhibitors can raise potassium levels, the primary concern with syncope is hypotension, not potassium imbalance. Increasing potassium without monitoring could lead to hyperkalemia.

D. Withhold the medication if pulse rate is less than 60/min: Enalapril primarily affects blood pressure, not heart rate. Withholding based on pulse rate is not appropriate; monitoring blood pressure is more relevant for safety and management of side effects.

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A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

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