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 B
Explanation
Choice A rationale
Contraction frequency every 3 minutes indicates an appropriate labor pattern with regular contractions and is not an indication to stop oxytocin.
Choice B rationale
Contraction duration of 100 seconds exceeds the normal range (usually less than 90 seconds), risking uterine hyperstimulation and fetal compromise, necessitating oxytocin discontinuation.
Choice C rationale
A fetal heart rate of 118/min falls within the normal range (110–160/min), indicating fetal well-being. Oxytocin does not need to be stopped.
Choice D rationale
Moderate variability in fetal heart rate demonstrates adequate fetal oxygenation and nervous system function, suggesting no oxytocin discontinuation is required.
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