Five days after giving birth, a client has slept very little and says, "A voice says my baby is evil and must be hurt." Which action should the nurse take first?
1Ask the client to describe the voice while the infant remains in the room
2Dim the lights, encourage sleep, and reassess the client later in the shift
3Ask the support person to take both the client and infant home and arrange a routine clinic visit
4Stay with the client, arrange supervised infant care, and activate emergency psychiatric care✓ Correct answer
Explanation
A command hallucination to harm an infant suggests postpartum psychosis, a psychiatric emergency. Maintain direct supervision, separate the infant into safe supervised care, and activate an emergency psychiatric response rather than leaving the client or delaying evaluation.
Quick answer Stay with the client, ensure the infant is safely supervised elsewhere, and activate emergency psychiatric evaluation. The command hallucination creates an immediate risk to both client and infant.
Why this is correct Postpartum psychosis can begin abruptly with severe insomnia, delusions, hallucinations, or disorganized behavior. Safety takes priority over detailed exploration because the client may act on a command or lose the ability to judge what is real.
Easy analogy or mental picture Treat the command hallucination like an active fire alarm: move vulnerable people to safety and summon emergency help before investigating every detail. The analogy explains priority but does not predict whether the client will act on the voice.
Memory hook Postpartum loss of reality plus harm commands means supervise, protect the infant, and escalate now.
NCLEX decision rule When psychosis includes a command to harm self or another person, establish immediate safety and continuous observation before therapeutic exploration. Postpartum psychosis requires urgent psychiatric assessment and usually hospital-level care.
Why the other choices are wrong Exploring the voice while the infant remains present does not control the immediate risk. Sleep support alone delays emergency care, and sending both home transfers a rapidly changing safety crisis outside a monitored setting.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
ACOG: Assessment and Treatment of Perinatal Mental Health ConditionsAmerican College of Obstetricians and Gynecologists