A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

Correct Answer: D

Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale: 1. Postpartum blues are common and typically resolve within a few days to a week postpartum. 2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells. 3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described. 4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation. 5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in

Correct Answer: A

Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.

Correct Answer: A

Rationale: The correct answer is A: This is more commonly seen in newborns who have dark skin. The bluish-brown marking described is likely a Mongolian spot, a common birthmark in darker-skinned infants. It is not related to hyperbilirubinemia (jaundice), forceps marks, or birth trauma. Mongolian spots are benign and typically fade over time. This statement is correct as it addresses the specific characteristic of the marking and its association with dark skin pigmentation in newborns.

Correct Answer: B

Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process. Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs. Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence. Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale: 1. Postpartum blues are common and typically resolve within a few days to a week postpartum. 2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells. 3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described. 4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation. 5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in

Correct Answer: B

Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks. Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age. Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age. Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.

Correct Answer: B

Rationale: The correct answer is B: Weakened uterine contractions. Terbutaline is a tocolytic medication that inhibits uterine contractions. This helps prevent preterm labor. At 28 weeks of gestation, the nurse would expect terbutaline to weaken uterine contractions, rather than increase fetal heart rate (choice A), enhance fetal lung surfactant production (choice C), or lower maternal blood glucose levels (choice D). Weakening of uterine contractions is the expected therapeutic effect of terbutaline in this scenario to delay preterm labor.

Correct Answer: D

Rationale: The correct answer is D: Covering the newborn's head with a cap. This is the highest priority as newborns are at risk for heat loss due to their large head surface area. By covering the newborn's head with a cap, heat loss can be minimized, helping to maintain the baby's body temperature. This is crucial for the newborn's overall well-being and to prevent complications such as hypothermia. Initiating breastfeeding (A) is important for newborn nutrition but can be delayed slightly without immediate harm. Performing the initial bath (B) can also wait as it is not as urgent as maintaining the newborn's temperature. Giving a vitamin K injection (C) is important for blood clotting but can be done after ensuring the baby's temperature is stable.

Correct Answer: D

Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.