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 A
Explanation
The correct answer is A.
A. Oligohydramnios: Oligohydramnios is a condition characterized by a lower-than-normal level of amniotic fluid in the uterus. Fetal assessment using electronic fetal monitoring may be indicated to monitor the well-being of the fetus, as oligohydramnios can be associated with fetal growth restriction and other complications.
B. Hyperemesis gravidarum: Hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy. While it can be a challenging condition, it is not typically an indication for electronic fetal monitoring. Fetal monitoring is generally performed for conditions that directly impact the well-being of the fetus.
C. Leukorrhea: Leukorrhea refers to an increase in vaginal discharge, which is a common and normal occurrence during pregnancy. It is not an indication for electronic fetal monitoring, as it does not directly impact fetal well-being.
D. Periodic tingling of the fingers: Periodic tingling of the fingers is not typically an indication for fetal assessment using electronic fetal monitoring. It may be related to factors such as nerve compression or changes in circulation but is not a direct indication for monitoring the fetus.
Correct Answer is A
Explanation
The correct answer is A. Assist the client to turn onto her side.
A. Assisting the client to turn onto her side is the correct intervention. This is because the client's blood pressure is low, and turning onto the side helps improve blood flow to the uterus, reducing the risk of supine hypotension.
B. Assisting the client to an upright position is not the priority in this case. The client is at risk for supine hypotension, and a lateral position is more appropriate.
C. Preparing for a cesarean birth is not indicated based solely on the blood pressure reading. Turning the client onto her side and monitoring the blood pressure response are appropriate initial actions.
D. Preparing for an immediate vaginal delivery is not indicated based solely on the blood pressure reading. The client's condition may improve with positional changes, and further assessment is needed.
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