A nurse is collecting data from a client who is 48 hr postpartum.
Which of the following findings reported by the client should the nurse identify as a postpartum psychosocial concern?
The newborn reminds the client of themself as a newborn.
The client reports fatigue and a desire to sleep.
The client does not want to feed the newborn.
The client discusses a desire to have more children.
The Correct Answer is C
Choice A rationale
Relating the newborn to oneself is a normal process during the "taking-hold" phase of maternal role attainment, typically occurring 2-10 days postpartum, where the mother focuses on the infant and parental role. This involves identifying the newborn as a separate individual while making comparisons, which is an expected psychosocial milestone and not indicative of a concern.
Choice B rationale
Postpartum fatigue and a desire to sleep are common physiological and psychological responses due to the physical exertion of labor, blood loss (normal postpartum blood loss is ≤ 500 mL for vaginal delivery), and interrupted sleep patterns. This is an expected finding and reflects the body's need for rest and recovery, not a pathological psychosocial concern within 48 hours.
Choice C rationale
The absence of desire to feed the newborn or a lack of interest in the infant can be an early indicator of postpartum blues or a more severe mood disorder like postpartum depression. Postpartum blues peaks around day five and resolves within two weeks, but a strong disinterest requires further assessment as it affects bonding and infant care.
Choice D rationale
Discussing the desire for future children indicates a healthy anticipation of a continued family life and is a sign of good adjustment and optimism regarding the maternal role and relationship. This finding is reassuring and signifies positive psychological adaptation rather than a postpartum psychosocial concern within this early timeframe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.
Choice B rationale
A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.
Choice C rationale
Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.
Choice D rationale
Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.
Correct Answer is ["B","E"]
Explanation
Choice A rationale
The instruction to avoid urinating at bedtime is incorrect and potentially harmful. Urinary stasis (urine sitting in the bladder) is a major risk factor for bacterial growth and recurrence of a urinary tract infection (UTI). Complete and frequent bladder emptying, including right before bed, is essential to flush out potential pathogens and prevent the ascent of bacteria, thereby minimizing the opportunity for bacterial proliferation within the urinary tract.
Choice B rationale
Wearing cotton-crotch underwear is recommended because cotton is highly breathable and absorbent, promoting air circulation and minimizing moisture retention in the perineal area. A dry environment inhibits the growth of bacteria and yeast, which can ascend into the urethra, potentially leading to a recurrent urinary tract infection (UTI). Synthetic fabrics trap heat and moisture, creating a more favorable medium for pathogen proliferation.
Choice C rationale
The instruction to eliminate yogurt products from the diet is incorrect. Yogurt containing live and active cultures (probiotics, such as Lactobacillus) can actually be beneficial. These beneficial bacteria may help maintain the normal balance of flora, especially in the vagina and surrounding area, which can inhibit the overgrowth of pathogenic bacteria (E. coli) that commonly cause urinary tract infections.
Choice D rationale
Douching is generally discouraged as it can disrupt the normal vaginal flora (primarily Lactobacillus), altering the protective acidic pH (normal 3.5-4.5). This disruption can increase the risk of both vaginal infections and ascending infections that may lead to a recurrent urinary tract infection (UTI). The vagina is a self-cleaning organ, and douching can inadvertently push bacteria higher into the reproductive or urinary tracts.
Choice E rationale
Refraining from taking bubble baths is a correct instruction. Soaps, detergents, and chemicals in bubble baths can cause irritation to the urethral meatus and surrounding tissues. This irritation makes the area more susceptible to colonization by bacteria, such as those from the perianal region, which can then ascend the urethra and lead to the development or recurrence of a urinary tract infection (UTI).
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