Editing Maternal and Newborn Nursing – RN Practice Questions (section)

==Question 15==
A nurse makes a home visit to a client 10 days after birth. The client states she has not slept in three days, believes her infant "has been replaced by a demon," and hears a voice telling her the baby must be protected from her. Which action should the nurse take?
# Reassure the client that postpartum blues are common and resolve within two weeks.
# Encourage the client to increase rest and follow up at the six-week postpartum visit.
# Arrange immediate psychiatric evaluation and ensure the infant is not left alone with the client.
# Screen the client with the Edinburgh Postnatal Depression Scale and refer for outpatient counseling.

'''Answer:''' 3 (C). Arrange immediate psychiatric evaluation and ensure the infant is not left alone with the client.

''Rationale:'' Delusions about the infant, auditory hallucinations, and severe insomnia with rapid onset in the first weeks describe '''postpartum psychosis''', a psychiatric emergency carrying substantial risk of suicide and infanticide. It requires urgent evaluation and usually inpatient treatment, and infant safety must be secured immediately. Option 1 is incorrect because postpartum blues involve tearfulness and mood lability without psychosis. Option 2 dangerously delays care. Option 4 is appropriate screening for postpartum ''depression'', but outpatient referral is not sufficient when psychotic symptoms and a command related to the infant are present.

[[Category:Maternal and Newborn Nursing]]
[[Category:Registered Nurse (NCLEX-RN)]]
{{Disclaimer}}