# Situation: The nurse is assigned to the labor, delivery, and postpartum units of a government hospital. At a 2-week postpartum visit, a 22-year-old mother completes the Edinburgh Postnatal Depression Scale (EPDS). Her total score is 8. On item 10 ("The thought of harming myself has occurred to me"), she chose "hardly ever." She is breastfeeding well and says she is only tired. Which action by the nurse is BEST?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse is assigned to the labor, delivery, and postpartum units of a government hospital.

At a 2-week postpartum visit, a 22-year-old mother completes the Edinburgh Postnatal Depression Scale (EPDS). Her total score is 8. On item 10 ("The thought of harming myself has occurred to me"), she chose "hardly ever." She is breastfeeding well and says she is only tired. Which action by the nurse is BEST?

## 보기

1. Reassure her that a total below 10 is a negative screen and repeat it at 6 weeks
2. Assess her suicide risk today before she leaves the clinic **✔ 정답**
3. Refer her for a routine counseling appointment within the next month
4. Explain that tiredness and low mood in the first weeks are postpartum blues

**정답: 2**

## 해설

Any positive response to EPDS item 10 (thoughts of self-harm) requires a same-day safety evaluation regardless of the total score. "Hardly ever" is a positive response, so the low total does not make the screen negative. The nurse asks directly about suicidal thoughts, plan, means, and intent before the client leaves.

## 심화 해설

Why the total score does not clear this mother

The Edinburgh Postnatal Depression Scale is a screening tool, not a diagnostic instrument, and its clinical value depends on how each item is interpreted. A total score below 10 is commonly used as a cutoff for a negative screen, but that rule applies only when there is no safety concern embedded in the responses. Item 10 asks directly about self-harm thoughts in the past 7 days, and any answer other than “never” is a positive response. In this case, the mother chose “hardly ever,” which means the thought has occurred to her at least once. A positive item 10 overrides the total score and requires a same-day suicide risk assessment.

What “hardly ever” means clinically

The frequency wording of item 10 can mislead clinicians into thinking that “hardly ever” is negligible. In population-based postpartum research, a positive response to item 10—including the lowest frequency option—is associated with a subsequent elevated risk of hospital-registered intentional self-harm, whether suicidal or non-suicidal [1]. The item does not measure severity; it measures presence of self-harm ideation. Therefore, the nurse must treat “hardly ever” as a red flag, not as a subthreshold finding. Key point! The EPDS item 10 is a screening question for ideation, not a risk-stratification scale; any endorsement triggers further evaluation.

Why reassurance or routine referral is unsafe

Option 1 assumes that a total score of 8 makes the screen negative. That is incorrect when item 10 is positive. The total score reflects depressive symptom burden, but self-harm ideation can occur even when the overall score is low. Option 3 delays evaluation by up to a month, which is unacceptable for a potential safety issue. Option 4 attributes the presentation to postpartum blues, a transient condition that does not include self-harm thoughts. Postpartum blues may include tearfulness and fatigue, but it does not explain a positive response to a self-harm screening item.

What the same-day safety evaluation includes

Before the mother leaves the clinic, the nurse asks directly about suicidal thoughts, including whether she has a plan, access to means, and intent to act. The nurse also assesses for protective factors such as the baby’s presence, social support, and the mother’s willingness to seek help. If the mother denies current suicidal ideation, the nurse still documents the positive item 10, arranges close follow-up, and provides crisis resources. If she endorses any plan or intent, the nurse initiates emergency psychiatric referral and ensures the mother is not left alone.

Screening tool limitations to keep in mind

Some researchers have questioned whether item 10 accurately captures suicide ideation and whether it causes distress, noting that the strongest endorsement (“yes, quite often”) is highly correlated with the full EPDS score . However, those concerns do not change the clinical protocol: a positive response still demands immediate clarification. Other work shows that suicidal ideation during the perinatal period is often assessed through the final items of the EPDS and PHQ-9, and that trajectories can shift between pregnancy and postpartum . Prevalence data also indicate that self-harm ideation is common enough in postpartum women to justify routine, careful follow-up of any positive screen . Watch out! Do not let a low total score or a soft frequency word like “hardly ever” delay a safety assessment.

| Comparison | EPDS total below 10 | Item 10 positive |
| --- | --- | --- |
| Interpretation | Low depressive symptom burden | Self-harm ideation present |
| Required action | Routine follow-up if item 10 negative | Same-day suicide risk assessment |
| Can total score override? | Not applicable | No; item 10 always takes priority |

The nurse’s best action is to assess suicide risk today, before the mother leaves the clinic, because a positive EPDS item 10—regardless of frequency or total score—signals the need for immediate safety evaluation [1].References (research sources)

- [1]Postpartum self-harm thoughts and subsequent risk of intentional self-harm.Research articleLiu X, Christiansen E, Bergink V, Kjeldsen MZ, Mægbæk ML, Munk-Olsen T (2026) · DOI: 10.1136/bmjment-2025-302282

## 임상 시나리오

EPDS Item 10: Same-Day Safety EvaluationAny self-harm ideation overrides the total score
A total EPDS score below 10 is a negative screen only when item 10 is answered "never". Any other response, including "hardly ever", is a positive self-harm item that overrides the total score.

The nurse must conduct a same-day suicide risk assessment before the client leaves, asking directly about suicidal thoughts, plan, means, and intent.

CautionDo not reassure, defer, or attribute the response to postpartum blues. A positive item 10 is a red flag for elevated risk of intentional self-harm, regardless of frequency wording.

## 핵심 개념

- **Edinburgh Postnatal Depression Scale (EPDS)** — A 10-item screening tool for perinatal depression; item 10 assesses self-harm ideation and any non-zero response requires immediate safety evaluation.
- **Positive item 10 response** — Any answer other than "never" on EPDS item 10, indicating self-harm thoughts have occurred; overrides total score and mandates same-day suicide risk assessment.
- **Postpartum blues** — A transient, self-limited mood disturbance occurring within the first 2 weeks postpartum, characterized by tearfulness and mood lability without self-harm ideation.
- **Suicide risk assessment** — A structured same-day evaluation of suicidal thoughts, plan, means, and intent conducted before the client leaves the clinical setting.
- **Screening vs. diagnostic tool** — EPDS is a screening instrument that identifies risk but does not diagnose; positive responses require further clinical evaluation.

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