The nurse is assessing a new mother at a health care facility.
Which symptom would the nurse identify as a symptom of postpartum blues?
Mild irritability.
Hallucinations.
Unwillingness to sleep.
Frantic energy.
The Correct Answer is A
Choice A rationale
Postpartum blues, a transient and mild form of mood disturbance experienced by up to 80.
Choice B rationale
Hallucinations are considered psychotic symptoms and are characteristic of a more severe condition, such as postpartum psychosis, not the common and self-limiting postpartum blues. Postpartum psychosis is a psychiatric emergency that can present with mood lability, disorganized behavior, delusions, and a high risk of harm to the mother or infant.
Choice C rationale
Unwillingness to sleep or severe insomnia is a more pronounced symptom that, if persistent, may suggest a more serious condition like postpartum depression or potentially postpartum psychosis, especially when combined with other affective or psychotic symptoms. The fatigue and sleep disturbance of postpartum blues is generally less severe.
Choice D rationale
Frantic energy or psychomotor agitation is not typical of postpartum blues. While women with blues may feel anxious, this intense symptom could suggest an underlying bipolar disorder presenting with a manic episode or be a feature of the more severe and acute onset of postpartum psychosis, necessitating immediate psychiatric evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing a rolled towel under the client's knees causes increased pressure on the popliteal space, potentially compressing the popliteal vein, which increases the risk of deep vein thrombosis (DVT) in the client. This is particularly concerning during labor due to physiologic hypercoagulability and potential for immobility. The priority action must focus on fetal and maternal well-being following rupture of membranes (ROM). This action is non-essential and potentially harmful.
Choice B rationale
While notifying the healthcare provider is crucial, it is not the immediate priority when there is a risk of a severe complication like umbilical cord prolapse following the spontaneous rupture of membranes (ROM). The nurse's immediate action must be to rule out or intervene for fetal distress or cord prolapse. The provider can be notified after the initial fetal status assessment is complete, especially the fetal heart rate (FHR).
Choice C rationale
Administering oxygen via a non-rebreather mask (NRB) is indicated for maternal or fetal hypoxemia or distress, or as part of resuscitation measures. In an initially stable client without signs of severe respiratory distress or non-reassuring fetal heart rate (FHR) patterns, oxygen administration is not the priority. The initial action must be a rapid assessment of fetal status, specifically ruling out cord prolapse after rupture of membranes (ROM).
Choice D rationale
Rupture of membranes (ROM) prior to the fetal head being engaged or firmly applied to the cervix creates a significant risk for umbilical cord prolapse, which is a fetal emergency causing acute fetal hypoxemia due to cord compression. The immediate priority is to assess the fetal heart rate (FHR) and perform a sterile vaginal exam (SVE) to palpate for the prolapsed cord and assess the presenting part. FHR assessment detects distress; SVE detects the prolapse.
Correct Answer is ["12"]
Explanation
Step 1 is to convert the oxytocin concentration from units to milliunits (mU):. 20 units× 1000 mU/unit = 20000 mU.
Step 2 is to determine the concentration in mU/mL:. 20000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is to calculate the infusion rate in mL/min:. 4 mU/min÷ (20 mU/mL) = 0.2 mL/min.
Step 4 is to convert the infusion rate from mL/min to mL/hr:. 0.2 mL/min× 60 min/hr = 12 mL/hr. The final calculated answer is 12 mL/hr.
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