Which observed behavior would indicate to the nurse that a post-partum client had progressed to the "taking hold" phase?

Requests time to talk on the phone

Hesitate to initiate contact with the newborn

Allows staff to perform most of the infant's care

Questions the nurse about frequency of feeding for the newborn

Answer and Explanation

The Correct Answer is D

A. Requests time to talk on the phone is more reflective of the "taking in" phase, where the mother is focused on herself and her own needs, such as resting and reflecting on the birth experience. This phase typically involves less engagement with the baby and more focus on recovery.

B. Hesitates to initiate contact with the newborn is characteristic of the "taking in" phase as well. During this phase, the mother may still be adjusting and may not yet feel confident in caring for her baby, often focusing more on her own recovery.

C. Allows staff to perform most of the infant's care is also more indicative of the "taking in" phase. During this phase, the mother is still learning and may feel less confident, often relying on others to care for the newborn.

D. Questions the nurse about frequency of feeding for the newborn is a behavior typically seen in the "taking hold" phase. During this phase, the mother becomes more active in caring for the baby, taking responsibility for its care, and showing interest in learning about the baby’s needs (such as feeding). This phase involves a shift toward becoming more independent and engaged in infant care.

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Correct Answer is B

Explanation

A. Weight gain and shortness of breath are common symptoms of pre-eclampsia or hypertension, but they are not specific to HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets). Shortness of breath could be due to other conditions, such as pulmonary edema, but it does not directly indicate HELLP syndrome.

B. Epigastric pain and elevated liver enzymes is a classic symptom of HELLP syndrome, a severe form of pregnancy-induced hypertension (PIH). The epigastric pain is often related to liver distention due to the liver damage and elevated liver enzymes. This is a key indicator of HELLP syndrome, which can be life-threatening if not managed promptly.

C. Edema of hands and feet of +2 is a common finding in pregnancy-related hypertension or pre-eclampsia but is not specific to HELLP syndrome. Mild edema (such as +2) can occur in many pregnancies and does not necessarily indicate the severity of the condition.

D. Fatigue and headache are symptoms commonly seen in pre-eclampsia and may also occur in HELLP syndrome, but they are less specific compared to epigastric pain and elevated liver enzymes, which are hallmark signs of HELLP syndrome.

A. difficulty in arousing B. deep tendons reflexes 2+ C. urinary output of 20 mL per hour D. respiratory rate of 10 breaths/minute

Correct Answer is B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

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Which observed behavior would indicate to the nurse that a post-partum client had progressed to the "taking hold" phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

Correct Answer is B

Explanation

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which factor would the nurse identify as being a significant contributor to this condition?

The nurse is caring for a client who is being treated with Magnesium Sulphate. Ordered 2g/hr Supplied 10g/250ml bag What would be the correct calculations for the maintenance dose in ml/hr

Which observed behavior would indicate to the nurse that a post-partum client had progressed to the "taking hold" phase?

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?