When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse’s primary concern in planning the client’s care?
Harm to herself or her infant.
Displaying outbursts of anger.
Neglecting her hygiene.
Losing trust in her husband.
The Correct Answer is A
Choice A rationale
Postpartum depression with psychotic features may lead to suicidal ideation or infanticidal tendencies due to delusions or hallucinations. Ensuring safety is critical to prevent harm to both mother and infant.
Choice B rationale
Anger outbursts, though concerning, do not pose immediate threats like harm to self or infant. Addressing this behavior is secondary to prioritizing safety in severe postpartum psychosis cases.
Choice C rationale
Neglecting hygiene reflects depressive symptoms but does not indicate psychosis severity or imminent danger. Primary focus remains on managing safety risks to the mother and infant.
Choice D rationale
Losing trust in her husband is relevant to interpersonal stress but does not constitute a primary care concern. The immediate threat of harm takes precedence over marital dynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
Correct Answer is C
Explanation
Choice A rationale
A respiratory rate of 75 breaths per minute exceeds the normal range of 30 to 60 breaths per minute in neonates. Tachypnea indicates distress, which necessitates immediate intervention to prevent complications.
Choice B rationale
A temperature of 96.5°F is below the normal neonatal range of 97.7°F to 99.5°F, suggesting hypothermia. This can impair enzyme activity, oxygen delivery, and thermoregulatory functions, requiring prompt warming measures.
Choice C rationale
Sucking or licking of the nipples reflects a positive response in kangaroo care, indicative of improved thermoregulation and bonding. This natural behavior also suggests a healthy neonate capable of initiating feeding.
Choice D rationale
Nasal flaring is a sign of respiratory distress, typically indicating increased effort to meet oxygen demands. This would not be considered a positive outcome and requires immediate evaluation and intervention.
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