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 A
Explanation
Choice A rationale
Anemia in pregnancy requires increased iron intake to support hemoglobin production, essential for oxygen transport in the blood. Iron-rich foods, such as red meat and leafy greens, are recommended.
Choice B rationale
Decreasing protein intake is counterproductive for anemic pregnant clients. Protein is vital for overall health and fetal development, and adequate intake should be maintained.
Choice C rationale
Calcium-rich foods are important but do not directly address anemia. They support bone health, and while necessary, they do not substitute the need for increased iron in anemic clients.
Choice D rationale
Vitamin C intake should be increased alongside iron-rich foods as it enhances iron absorption. However, increasing vitamin C alone does not suffice to correct anemia without adequate iron intake.
Correct Answer is B
Explanation
Choice A rationale
Breastfeeding a newborn 6-8 times a day is insufficient. Newborns typically need more frequent feedings to ensure adequate nutrition and growth, generally more than 8 times.
Choice B rationale
Newborns should be breastfed 8-12 times in a 24-hour period. This frequent feeding ensures they receive enough nutrients, helps establish milk supply, and supports healthy growth.
Choice C rationale
Feeding 10-14 times a day can be appropriate for some newborns but may not be necessary for all. The standard recommendation is 8-12 times, balancing nourishment and mother's comfort.
Choice D rationale
Breastfeeding 12-16 times a day is excessive and may cause maternal fatigue and discomfort. The general guideline of 8-12 times is sufficient to meet a newborn's nutritional needs.
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