The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:

decrease the heart rate of the fetus

Aid the women while she pushes

prevent supine hypertension

prevent the client from falling out of bed

Answer and Explanation

The Correct Answer is C

A) Decrease the heart rate of the fetus:
Lying on the left side can sometimes help improve fetal oxygenation, especially if there is a concern about reduced blood flow from compression of the inferior vena cava, which can occur when the mother lies on her back. However, the primary rationale for this position is to prevent supine hypotension, not specifically to decrease fetal heart rate. In fact, side-lying can promote better oxygen exchange, which can indirectly benefit the fetal heart rate.

B) Aid the women while she pushes:
While a left-side lying position may offer comfort during labor and can help with uterine positioning, it is not specifically intended to aid in the pushing phase. Positions such as squatting or hands-and-knees are generally more helpful during the pushing phase because they can facilitate effective pushing and help the baby descend into the birth canal. The left-side position is more about circulation and preventing hypotension.

C) Prevent supine hypertension:
Supine hypotension occurs when the pregnant woman lies flat on her back, which can compress the inferior vena cava and reduce blood return to the heart. This leads to a drop in blood pressure and can compromise both maternal and fetal circulation. The left-side position is recommended because it helps to prevent this compression and allows optimal blood flow to both the mother and fetus, improving oxygenation and circulation.

D) Prevent the client from falling out of bed:
While lying on the left side may make the woman feel more stable, the primary reason for this position is to prevent supine hypotension, not to prevent her from falling out of bed. The nurse would ensure safety by using appropriate bed rails and monitoring, but the primary concern is supporting optimal circulation, not preventing falls.

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Correct Answer is D

Explanation

A) Sublimation:
Sublimation refers to a defense mechanism where a person redirects potentially negative emotions or impulses into socially acceptable behaviors or activities. While this is a psychological concept, it does not apply to the father’s behavior immediately after birth. The father's actions, such as gazing at his baby and bonding, are not a result of sublimation but rather a normal part of bonding and attachment.

B) Claiming:
Claiming refers to the process where parents identify specific traits or characteristics in their newborn that they feel emotionally connected to, such as "He has my eyes" or "She has your nose." While the father might be engaging in claiming behaviors as he bonds with his baby, this term is more focused on recognizing physical attributes, rather than the intense emotional connection and captivation that is reflected in the scenario.

C) Mutuality:
Mutuality involves the reciprocal relationship between the newborn and the parents, where both give and receive emotional responses. It develops as the baby and parent interact, such as through eye contact, touch, and vocalizations. However, mutuality is a broader, ongoing process, while the father's behavior in this instance reflects a more specific emotional attachment and admiration, which aligns more closely with engrossment.

D) Engrossment:
Engrossment refers to the intense fascination and preoccupation that a parent, especially a father, feels toward their newborn. This process is characterized by behaviors such as gazing at the baby, holding them closely, and being captivated by their every movement. The father’s behavior in this scenario—staring into his baby’s eyes and showing deep emotional engagement—fits the definition of engrossment, which is a common and normal part of the bonding process immediately after birth.

A. Dry and stimulate newborn with towel. B. Place a hat on the newborn's head. C. Maintain the delivery room temperature at 20° C (68° F) D. Place a blanket on top of maternal dent and newborn.

Correct Answer is C

Explanation

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.

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The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:

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Naxlex Comprehensive Predictor Exams

Immediately after birth, the father of the newborn holds the baby close, stares into his eyes, and seems captivated by him. The nurse recognizes this as the normal process of:

Correct Answer is D

Explanation

A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

Correct Answer is C

Explanation

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