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 C

Explanation

A. Ferning is a test to detect ferning patterns in amniotic fluid under a microscope. A positive result indicates the presence of amniotic fluid but does not suggest infection.

B. Yellow-green fluid may suggest meconium-stained amniotic fluid, which is often associated with fetal distress, but it does not directly indicate infection. However, it can increase the risk of infection if the meconium is aspirated by the baby.

C. Foul odor is a key sign that infection may be present, particularly in the case of chorioamnionitis, an infection of the fetal membranes. A foul odor in the amniotic fluid suggests the presence of bacteria and should raise concern for infection, requiring prompt intervention.

D. Blue color on Nitrazine testing indicates that the amniotic fluid is alkaline, which is expected and normal, as amniotic fluid typically has a pH of 7-7.5. This test is used to confirm the rupture of membranes, not infection.

A. Limit the amount of time the infant nurses on each breast B. Apply nipple shields when not breastfeeding the infant C. Instruct client to apply lanolin-based product to nipples D. Ensure that the client positions and latches the infant correctly on the breast

Correct Answer is D

Explanation

A. Limit the amount of time the infant nurses on each breast is not an effective strategy for preventing sore nipples. The issue is usually related to poor latch or positioning, not the duration of breastfeeding. Limiting nursing time could negatively impact milk supply and bonding.

B. Apply nipple shields when not breastfeeding the infant is not typically recommended as a preventive measure for sore nipples. Nipple shields are more often used to assist with latching problems, not to prevent soreness. Prolonged use can sometimes contribute to nipple confusion and further complications.

C. Instruct client to apply lanolin-based product to nipples can provide temporary relief for sore or cracked nipples, but it does not prevent soreness. The root cause of nipple pain is often related to improper positioning and latch, so this is more of a remedy than a preventive measure.

D. Ensure that the client positions and latches the infant correctly on the breast is the most effective way to prevent sore nipples. A proper latch ensures that the infant is effectively removing milk and reduces the likelihood of nipple trauma. The nurse should help the client with correct positioning, ensuring that the infant's mouth covers a large portion of the areola, not just the nipple.

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

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Naxlex Comprehensive Predictor Exams

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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