A postpartum woman is in the perinatal clinic for a routine ...

[Shelles]

A postpartum woman is in the perinatal clinic for a routine follow-up visit with her new infant. The patient seems agitated by the questions the nurse is asking and often looks up at the ceiling apprehensively. What action by the nurse is best?
 
  A.
  Ask the woman if she is hearing voices.
  B.
  Assess the woman's sleep and nutrition.
  C.
  Determine if the woman has any support.
  D.
  Take the baby to another room for assessment.

Question 2

A woman with a deep vein thrombosis (DVT) is receiving IV heparin therapy. Which nursing diagnosis does the nurse address as the priority?
 
  A.
  Altered family processes
  B.
  Pain
  C.
  Risk for injury
  D.
  Self-care deficit

[lorealeza]

Answer to Question 1

ANS: A
This woman may be displaying signs of postpartum psychosis, which include hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality. The most specific question the nurse can ask is about hallucinations because the woman is looking up at the ceiling. Many new mothers have sleep disturbances, so this would not be the priority question to ask. Assessing the woman's social support is not a priority. Taking the infant away from the mother would only be needed if the infant were in immediate danger, and this action may agitate the woman further. The nurse should alert others, remain with the mother, and conduct further assessments.

Answer to Question 2

ANS: C
Heparin has many side effects, including a risk for bleeding. The patient on IV heparin is at high risk for injury. The other diagnoses are important, but safety takes priority.

[Shelles]

Gracias!

[Alyson.hiatt@yahoo.com]

Excellent