Level: Clinical
Difficulty: Medium
Subtopic: Postpartum assessment
NCLEX: A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data include the client reports calf pain with unilateral warmth and swelling. Which nurse response best supports psychosocial integrity?
Question
A. False reassurance that nothing is wrong.
B. Changing the subject when the client expresses fear.
C. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
B. Changing the subject when the client expresses fear.
C. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
D. Promising outcomes that cannot be guaranteed.
Rationale
Correct answer: C. Therapeutic presence, active listening, validation, and suicide or violence screening when indicated.
Rationale: Psychosocial integrity items reward therapeutic communication and appropriate safety screening, not avoidance or false promises.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Psychosocial integrity items reward therapeutic communication and appropriate safety screening, not avoidance or false promises.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.