A postpartum mother presents to the healthcare clinic for her 6 week postnatal check-up. During the assessment, she expresses feelings of overwhelming sadness, hopelessness, and guilt.
She also mentions a loss of interest in activities she once enjoyed and difficulty bonding with her newborn.
Which nursing action is most appropriate for the nurse to take in this situation?
Provide education on the normal and expected emotional changes experienced during the postpartum period.
Ensure she is not left alone in the room with the baby while you prepare to transfer her to inpatient psychiatric care.
Conduct a comprehensive assessment of the mother's mental health and refer her for further evaluation and support.
Reassure the mother that these feelings will resolve on their own as she adjusts to motherhood.
The Correct Answer is C
10 A postpartum mother presents to the healthcare clinic for her 6 week postnatal check-up. During the assessment, she expresses feelings of overwhelming sadness, hopelessness, and guilt. She also mentions a loss of interest in activities she once enjoyed and difficulty bonding with her newborn. The correct answer is Choice C.
Choice A rationale
Providing general education about "baby blues" is inappropriate and minimizes the mother's severe symptoms of intense hopelessness, overwhelming guilt, and anhedonia (loss of interest). Postpartum blues are transient, mild mood disturbances peaking around day 3-5 and resolving by two weeks, whereas this mother’s symptoms at six weeks strongly suggest Postpartum Depression (PPD), which requires professional intervention, not just reassurance.
Choice B rationale
Transfer to inpatient psychiatric care is not the immediate first action unless the mother expresses overt thoughts or plans for suicide or infanticide, which is not explicitly stated. The most appropriate initial step is a comprehensive, focused mental health assessment to determine the severity of her risk and the correct level of care, which may ultimately lead to referral for outpatient or inpatient treatment.
Choice C rationale
The mother's cluster of symptoms—sadness, hopelessness, anhedonia, and difficulty bonding at six weeks postpartum—meets the diagnostic criteria for a major depressive episode, highly indicative of PPD. The most appropriate nursing action is to formally assess her mental state, including screening for suicidal or self-harm ideation, and then provide an immediate and specific referral to a mental health specialist (psychiatrist or therapist) for treatment.
Choice D rationale
Reassuring the mother that her significant symptoms of depression will resolve on their own is medically and ethically incorrect. PPD is a serious, non-self-limiting condition that requires timely and sustained professional treatment, such as psychotherapy and/or antidepressant medication, and will not typically resolve spontaneously. Untreated PPD can negatively impact mother-infant bonding and long-term child development. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A uterine hematoma typically presents with unrelenting pain and may cause signs of hypovolemic shock, which would be evidenced by tachycardia and hypotension, not necessarily a displaced, high fundus as a primary sign. While a Complete Blood Count (CBC) can detect associated anemia (normal hemoglobin is 12-16 g/dL), the immediate priority is addressing the fundus's position.
Choice B rationale
A full or distended urinary bladder pushes the uterus superiorly and laterally, commonly to the right side due to anatomical arrangement, causing it to be palpable above the expected level. This displacement inhibits proper uterine contraction and increases the risk of postpartum hemorrhage. The most appropriate initial intervention is to have the woman void or catheterize her, then reassess the fundus's position and tone.
Choice C rationale
While prolonged positioning can influence physical findings, the bladder's mechanical displacement of the uterus is a more common and clinically significant cause of a fundus displaced high and to the side in the immediate postpartum period. Simply changing position will not resolve the underlying issue of bladder distension, which compromises uterine hemostasis and must be addressed immediately.
Choice D rationale
While the health care provider must be informed of abnormal findings, contacting them is not the first action when a correctable physiological cause is highly suspected. The nurse should first attempt the least invasive intervention, which is addressing the likely full bladder, a common cause of this finding, and then reassess before escalating care. —.
Correct Answer is D
Explanation
Choice A rationale
Checking the newborn's temperature provides a baseline and monitors the effectiveness of warming interventions, but it is not the first action to assist in thermoregulation, which involves immediate heat loss prevention. A normal newborn axillary temperature range is approximately 36.5°C to 37.5°C (97.7°F to 99.5°F). Monitoring is secondary to immediate interventions to prevent rapid heat loss via evaporation.
Choice B rationale
Putting a hat on the newborn's head is an effective measure to reduce heat loss through convection and radiation from the large surface area of the head. However, evaporation is the most rapid heat loss mechanism immediately following birth due to the wet skin. Therefore, drying the newborn takes immediate priority over applying a hat for initial stabilization.
Choice C rationale
Wrapping the newborn in a warm blanket prevents heat loss primarily through convection and radiation. While vital for sustained thermoregulation, this step is most effective after the initial heat loss via evaporation has been minimized by thoroughly drying the neonate's skin surface immediately upon delivery.
Choice D rationale
Drying the newborn thoroughly is the essential first action for thermoregulation because it prevents heat loss through evaporation. Evaporation of amniotic fluid from the newborn's moist skin surface causes very rapid heat loss, especially considering the newborn's large surface area to body mass ratio and limited subcutaneous fat for insulation. —.
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