A nurse observes a new mother avoiding eye contact and hesitating to hold the infant.
She expresses frustration during feeding attempts and during your last rounding she states the last time the baby attempted to nurse was 5 hours ago.
What should the nurse do first to address this issue and promote bonding?
Assign all newborn care to the father of the baby.
Explore the mother's feelings and provide reassurance to reduce anxiety.
Document the behavior and place a social service consult.
Take the newborn to the nursery until the mother is ready.
The Correct Answer is B
Choice A rationale
Assigning all newborn care to the father does not address the mother's apparent emotional distress or promote her direct involvement, which is crucial for establishing the initial maternal-infant bond. The priority is to explore the mother's feelings and underlying reasons for her withdrawal to facilitate a healthy attachment and provide appropriate support.
Choice B rationale
The initial priority is a therapeutic assessment to understand the mother's perspective. Avoiding eye contact, hesitating to hold the infant, and expressing frustration are behaviors suggestive of anxiety, fear, or potential postpartum blues. Exploring these feelings first, with a nonjudgmental approach, provides the foundation for building trust and planning further necessary interventions.
Choice C rationale
While documentation and social service consultation may be necessary later, the immediate step should be a direct, nurse-led intervention to address the risk of poor bonding and potential feeding complications (like 5 hours since last attempt) by engaging with the mother. Immediate psychosocial support is a nursing responsibility before a referral.
Choice D rationale
Taking the newborn to the nursery is a separating intervention that should be avoided unless the infant's safety is compromised. The goal is to keep the dyad together and facilitate bonding. Removing the baby validates the mother's avoidance and hinders the development of her maternal confidence and attachment to the infant. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While encouraging early breastfeeding promotes bonding, provides optimal nutrition, and stimulates uterine involution, the immediate priority for a macrosomic infant, especially after a difficult delivery with an APGAR score of 7/9 (normal), is addressing the high risk of hypoglycemia due to hyperinsulinemia from maternal glucose exposure; therefore, metabolic stability precedes routine bonding.
Choice B rationale
Preparing for immediate transfer to the NICU is only warranted if the infant exhibits significant respiratory distress, persistent hypoglycemia refractory to intervention, or severe birth injuries like an unstable fracture or extensive nerve palsy; as the infant's APGAR scores (7/9) and stability suggest initial adequate transition, this action is premature without further assessment and intervention.
Choice C rationale
Documenting the birth weight of 4550 grams confirms the diagnosis of macrosomia (birth weight >4000 grams), which signals a high-risk status; however, simply continuing routine care ignores the well-established associated risks such as birth trauma (e.g., shoulder dystocia) and, most importantly, hypoglycemia (blood glucose <40-45 mg/dL), which requires immediate monitoring.
Choice D rationale
Monitoring blood glucose levels is crucial, as macrosomic infants are at high risk for hypoglycemia due to maternal diabetes leading to fetal hyperinsulinism, which continues after the umbilical cord is cut; initiating feedings as soon as possible provides a necessary glucose source to prevent or correct hypoglycemia and should be the primary action following stabilization.
Correct Answer is C
Explanation
Choice A rationale
Palpating the fundus 2 cm above the symphysis pubis is typically found immediately following birth or within the first 12 hours postpartum. The uterus begins the process of involution immediately after birth, rapidly descending into the pelvis. By 24 hours postpartum, the fundus should be roughly at the level of the umbilicus, making this choice incorrect for 24 hours postpartum.
Choice B rationale
Finding the uterine fundus 2 cm above the umbilicus is a finding that is expected immediately after birth, usually within the first hour. The fundus rapidly descends to the level of the umbilicus by 24 hours postpartum, due to the sustained uterine contractions that decrease its mass and volume through the catabolic process of autolysis.
Choice C rationale
The uterine fundus is expected to be at the level of the umbilicus or 1 to 2 cm below the umbilicus approximately 24 hours after birth. Involution, the process of the uterus returning to its non-pregnant state, causes the fundus to descend by about 1 cm or one finger breadth each day.
Choice D rationale
While the fundus is often at the level of the umbilicus at 24 hours postpartum, it's more precise to say it may be slightly lower, 1 to 2 cm below it. This rapid descent is due to uterine contractions reducing the size of the myometrium, driven by oxytocin release from the posterior pituitary gland in response to breastfeeding or administration. —.
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