A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition?
Flat affect and loss of interest in activities.
Sadness with mood swings and tearfulness.
Insomnia with anxiety about infant care.
Delusional thinking and hallucinations.
The Correct Answer is D
Choice A rationale
A flat affect and loss of interest in activities, known as anhedonia, are characteristic symptoms often associated with postpartum depression (PPD). Postpartum psychosis (PPP) is a severe condition marked by an abrupt onset of prominent psychotic features, which typically include a more dramatic and acute presentation rather than the blunted emotional responses seen in PPD.
Choice B rationale
Sadness, mood swings, and tearfulness are classic and common features of the postpartum blues, a transient and mild condition affecting up to 85.
Choice C rationale
Insomnia coupled with anxiety about infant care, particularly excessive worry, is frequently seen in postpartum depression and postpartum anxiety. Postpartum psychosis presents as a more profound disturbance in reality testing, characterized by the presence of psychotic symptoms like delusions and hallucinations, not just heightened anxiety or simple sleep disturbances.
Choice D rationale
Delusional thinking, which involves false, fixed beliefs, and hallucinations, which are sensory perceptions without external stimuli, are the hallmark psychotic symptoms that define postpartum psychosis (PPP). PPP is a medical emergency requiring immediate psychiatric intervention due to the high risk of harm to the mother and/or infant associated with the severe impairment in reality testing. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The APGAR scoring system is a rapid assessment tool for a newborn's transition to extrauterine life, typically performed at one and five minutes after birth. Oxygen saturation and alertness are not standard components of the five criteria. The five physiological signs utilized are 𝐇eart rate, 𝐑espiratory effort, 𝐌uscle tone, 𝐑eflex irritability, and 𝐂olor (Appearance). This specific combination is inaccurate for the established APGAR protocol.
Choice B rationale
Movement is assessed under Muscle Tone, and cry is an indicator of Respiratory Effort and Reflex Irritability, but they are not the primary, distinct physiological parameters. Temperature is a critical newborn vital sign but is not one of the five specific criteria used in the APGAR scoring system. The acronym APGAR (Appearance, Pulse, Grimace, Activity, Respiration) represents the five core physiological signs assessed.
Choice C rationale
The APGAR scoring system utilizes five distinct physiological signs: 𝐏ulse (Heart rate), 𝐆rimace (Reflex irritability), 𝐀ctivity (Muscle tone), 𝐑espiration (Respiratory effort), and 𝐀ppearance (Color). Each is scored 0, 1, or 2, summing to a total score of 0-10, providing an immediate evaluation of the newborn's cardiorespiratory and neurological status to guide necessary resuscitation or support.
Choice D rationale
Capillary refill and blood pressure are important indicators of circulatory status but are not part of the standard, rapid, five-component APGAR assessment conducted at one and five minutes. The APGAR system prioritizes quickly observable and measurable functions: heart rate (auscultation), respiratory effort (observation), muscle tone, reflex irritability, and overall color (visual/tactile). —.
Correct Answer is D
Explanation
A 28 year old G1 delivered 16 hours ago via forceps assisted vaginal delivery of a 9lb 2 oz male infant with a 4th degree repair.
Estimated blood loss (EBL) was 378 mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen.
Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300 cc of clear yellow urine 4 hours ago.
Bowel sounds are active and she is passing gas but has had no bowel movement since delivery.
The patient asks you what are some of the risk factors that made her have such a bad laceration and what are the best practices for perineal care in the postpartum period?
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