A nurse is assessing a client who gave birth 1 week ago.
The client states, "I don't know what's wrong.
I love my baby, but I feel so let down and I seem to cry for no reason.”. The nurse should identify that the client is experiencing which of the following emotional responses to birth?
Postpartum depression.
Taking-in phase.
Postpartum blues.
Taking-hold phase.
The Correct Answer is C
Choice A rationale
Postpartum depression involves persistent sadness and impaired functioning, typically lasting longer than two weeks. This client’s symptoms suggest a more transient condition.
Choice B rationale
The taking-in phase refers to the period immediately postpartum when the mother focuses on her own needs, not emotional instability as described.
Choice C rationale
Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
Choice D rationale
The taking-hold phase involves active learning about infant care and maternal adjustment, not the emotional lability described in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Occipital bruising typically results from birth trauma due to compressive forces during delivery. While notable, it isn’t necessarily pathological in the context of common neonatal findings.
Choice B rationale
Yellowish sclera and blanching skin indicate neonatal jaundice from elevated bilirubin levels. Hyperbilirubinemia arises due to immature hepatic conjugation processes, necessitating close monitoring for kernicterus risk.
Choice C rationale
A transcutaneous bilirubin level of 12.5 mg/dL exceeds normal (<12 mg/dL) for newborns, indicating hyperbilirubinemia. It reflects excessive hemolysis or liver immaturity requiring therapeutic interventions like phototherapy.
Choice D rationale
Phototherapy at 08: targets bilirubin breakdown into water-soluble forms for excretion. Blue light exposure facilitates reduced serum bilirubin levels, mitigating neonatal jaundice complications promptly. .
Correct Answer is C
Explanation
Choice A rationale
Amnioinfusion addresses variable decelerations by relieving cord compression; however, discontinuing oxytocin to prevent further decelerations precedes procedural interventions for labor augmentation.
Choice B rationale
Vaginal/speculum exams are not the priority during recurrent variable decelerations as they delay immediate measures addressing cord compression and fetal oxygenation concerns.
Choice C rationale
Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
Choice D rationale
Instructions about potential birth preparation are important but not immediate for addressing variable decelerations, as they do not directly resolve underlying cord compression concerns. .
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