A nurse is caring for a patient who has postpartum psychosis. Which of the following actions is the nurse’s priority?
Reinforce the need to take antipsychotics as prescribed.
Monitor the infant for indications of failure to thrive.
Ask the patient if they have thoughts of harming themselves or their infant.
Review the client’s medical record for a history of bipolar disorder.
The Correct Answer is C
Choice A rationale
While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.
Choice B rationale
Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.
Choice C rationale
Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.
Choice D rationale
Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.
Choice B rationale
Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.
Choice C rationale
Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.
Choice D rationale
Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.
Correct Answer is D
Explanation
Choice A rationale
Skin lesions are not typically associated with gonorrheal infections, they are more indicative of other infections like congenital syphilis.
Choice B rationale
Vaginal or penile discharge indicates a localized infection rather than a systemic issue like neonatal conjunctivitis.
Choice C rationale
Thrush is a fungal infection caused by Candida, not related to gonorrheal infection.
Choice D rationale
Eye infection, specifically conjunctivitis (ophthalmia neonatorum), is common in newborns exposed to gonorrhea during birth.
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