A postpartum nurse is providing care to a new mother who delivered her baby two days ago.

She scored a 3 on her Edinburgh Depression Scale on admission to the postpartum unit.

The mother appears tearful, anxious, and expresses feelings of inadequacy in her new role.

Which action by the nurse is most appropriate when addressing the mother's condition?

Choice A rationale

A hemorrhoid is a swollen, inflamed vein in the rectum or anus, which can cause pain and pressure, especially after the strenuous process of childbirth and pushing. While possible, the combination of increasing perineal pain, rectal pressure, and inability to void following a forceps delivery and a third-degree laceration is more indicative of a deeper tissue injury or collection of blood than an external or internal hemorrhoid alone.

Choice B rationale

A bladder infection, or cystitis, typically presents with symptoms such as dysuria (painful urination), urgency, frequency, and sometimes hematuria, often appearing later in the postpartum course. While urinary retention is a risk after birth trauma, an infection is less likely to be the immediate cause of acute, rapidly increasing rectal pressure and severe perineal pain just three hours after delivery.

Choice C rationale

Uterine atony is the failure of the uterus to contract sufficiently after childbirth, which is the most common cause of postpartum hemorrhage. The assessment states the fundus is firm and the lochia is moderate without clots, which rules out significant uterine atony as the primary issue causing the localized, intense perineal and rectal discomfort.

Choice D rationale

A vaginal or vulvar hematoma is a collection of blood in the connective tissue, often resulting from trauma during delivery, especially with forceps, episiotomy, and deep lacerations. Its rapid expansion causes severe, unremitting, localized pain, rectal pressure (from mass effect), and can lead to urinary retention by distorting the urethra, which perfectly aligns with the patient's acute symptoms. —.

Choice A rationale

Initial hearing screens often yield false-positive results due to residual amniotic fluid, vernix caseosa, or middle ear effusion that can interfere with the sound transmission within the ear canal. The American Academy of Pediatrics recommends rescreening infants who fail the initial test, typically before discharge, to allow time for the ear canal to clear. If the infant fails the repeat screening, a definitive diagnostic evaluation is then necessary.

Choice B rationale

Scheduling an immediate specialist consult is premature after a single failed screening. Most initial failures resolve upon rescreening, which is the standard of care to avoid unnecessary anxiety and medical appointments. A referral is only warranted after the newborn fails the repeat screening to confirm a possible permanent hearing loss with a more comprehensive audiologic assessment within a few weeks.

Choice C rationale

A failed initial hearing screen does not automatically signify a permanent disability or necessitate an immediate social services consult. The focus remains on re-evaluation and appropriate follow-up. While providing comfort is always essential, escalating to social services based on a single failed screen is an overreaction and not the correct clinical intervention at this stage.

Choice D rationale

Initiating speech therapy services is inappropriate because the newborn's ability to hear has not yet been definitively determined. Speech therapy is implemented much later, usually when a confirmed hearing impairment impacts language development, typically after 6 months of age. The current priority is to confirm or rule out hearing loss via rescreening and diagnostic testing. —.