A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?
Discuss contraceptive options with the client and her partner.
Repeat information to ensure client understanding.
Listen to the client and her partner as they reflect upon the birth experience.
Demonstrate to the client how to perform a newborn bath
The Correct Answer is D
A. Discuss contraceptive options with the client and her partner. Discussing contraceptive options typically occurs later in the postpartum period, often during follow-up visits. This is not a priority during the early taking-hold phase, when the mother is focused on learning to care for herself and her baby.
B. Repeat information to ensure client understanding. Repeating information and ensuring understanding is more critical during the taking-in phase, which occurs in the first 24 to 48 hours postpartum, when the mother is more passive, fatigued, and focused on her own recovery. In the taking-hold phase, the mother is typically more alert and eager to learn.
C. Listen to the client and her partner as they reflect upon the birth experience. Reflecting on the birth experience is more aligned with the taking-in phase, when the mother is focused on herself and may need emotional support in processing the experience.
D. Demonstrate to the client how to perform a newborn bath. In the taking-hold phase, the mother is ready to take responsibility for the care of her newborn and actively seeks guidance. Demonstrating how to bathe the newborn is an appropriate intervention, as it provides practical support and helps the mother gain confidence in newborn care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Observe for crowning.
A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.
B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.
C. Observing for crowning is the correct action.
Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.
D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.
Correct Answer is D
Explanation
A. The cervix being effaced is not represented by the -1 notation in a vaginal examination. Effacement is usually expressed as a percentage.
B. The -1 notation does not represent cervical dilation. Dilation is measured in centimeters.
C. The presenting part being 1 cm below the ischial spines is not correct. In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
D. The presenting part is 1 cm above the ischial spines is the correct interpretation.
In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
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