The nurse is assessing the client's transition to the taking-hold phase after an uncomplicated vaginal birth.
Which behavior by the mother best indicates this transition is occurring?

Focuses primarily on her own needs.

Is very excited and talkative about the birth experience.

Is interested in learning more about infant care.

Relies on nursing staff for assistance.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.

Choice B rationale

Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.

Choice C rationale

Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.

Choice D rationale

Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.

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Correct Answer is D

Explanation

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Assist the family to identify prior use of positive coping skills in family crises. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is A

Explanation

Choice A rationale

Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .

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The nurse is assessing the client's transition to the taking-hold phase after an uncomplicated vaginal birth.Which behavior by the mother best indicates this transition is occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

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The nurse is assessing the client's transition to the taking-hold phase after an uncomplicated vaginal birth.
Which behavior by the mother best indicates this transition is occurring?