A nurse is collecting data from a client who is 6 weeks postpartum. The client tells the nurse, "I am not a good mother. My baby doesn't like me.” Which of the following actions should the nurse take?
Advise the client that most new mothers experience these feelings.
Ask the client if they have had thoughts about harming their infant.
Explain to the client they are experiencing the "baby blues.”
Take the client to the emergency department.
The Correct Answer is B
Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.
Choice A reason:
The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.
Choice C reason:
The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.
Choice D reason:
Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The nurse should not tell the client to lie flat on their back for the duration of the nonstress test. It is essential for pregnant clients to be in a semi-reclining or left lateral position during the test to avoid supine hypotension syndrome. This condition can occur when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and potentially compromising the baby's well-being.
Choice B reason:
The nurse should not instruct the client to lightly brush their palms across their nipples during the test. This statement is not related to the nonstress test procedure. The nonstress test involves monitoring the baby's heart rate in response to its movements, and nipple stimulation is not a standard part of the test.
Choice C reason:
The nurse should not advise the client not to eat or drink anything for 4 hours before the test. It is important for pregnant clients to have adequate nutrition and hydration, especially during the third trimester. Restricting food and drink for such a prolonged period could lead to dehydration and may not be necessary for the test.
Choice D reason:
This is the correct choice. During a nonstress test, the client is connected to a fetal heart rate monitor. They are asked to press a button whenever they feel the baby moving. This allows the healthcare provider to correlate the baby's movements with changes in the heart rate pattern, which helps assess the baby's well-being.
Correct Answer is C
Explanation
"I will reinforce the patch edges with clear tape if they don't lie flat.".
Choice A reason:
Placing a heat pack on the patch to improve adhesion is not recommended. Heat can potentially increase the absorption of the medication and lead to adverse effects. Applying additional heat to the patch can be dangerous and may cause an overdose or other complications.
Choice B reason:
Placing the patch on the back side of the child's arm is not the correct application site for a methylphenidate transdermal patch. The appropriate site for application is typically the hip or the top of the buttocks. The back of the arm may not provide proper absorption and can result in suboptimal medication delivery.
Choice C reason:
This statement indicates an understanding of the teaching. Reinforcing the patch edges with clear tape if they don't lie flat is a recommended step to ensure proper adhesion of the patch. If the edges of the patch lift or don't stick properly, using clear tape can help keep the patch securely in place, ensuring continuous and consistent drug delivery.
Choice D reason:
Leaving the patch in place for no more than 9 hours is incorrect. The duration of wear for a methylphenidate transdermal patch varies depending on the specific brand and formulation. Typically, these patches are designed for 9 to 12 hours of wear, and leaving them on for a shorter duration may result in inadequate symptom control.
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