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 A

Explanation

A. Elevated liver enzymes is a key indicator of HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a severe form of preeclampsia and can lead to liver damage. Elevated liver enzymes, such as AST and ALT, are a hallmark of this condition, indicating liver dysfunction.

B. Elevated platelet count would be the opposite of what is expected in HELLP syndrome. In HELLP syndrome, there is typically low platelet count (thrombocytopenia), not an elevated one.

C. Leukocytosis refers to an increased white blood cell count, which can be indicative of an infection or inflammation, but it is not a hallmark of HELLP syndrome. HELLP syndrome primarily involves hemolysis, liver enzyme elevation, and low platelets.

D. Hyperglycemia is not a characteristic finding of HELLP syndrome. While it can occur in some pregnancy-related conditions, it is not specifically associated with HELLP syndrome. This condition is more associated with elevated liver enzymes and low platelets.

A. 0.75ml B. 15ml C. 1.5 ml D. 0.9ml

Correct Answer is C

Explanation

A. 0.75 mL would provide only 1.5 mg, which is half the prescribed dose
B. 15 mL would provide 30 mg, which is ten times the prescribed dose and could be dangerously toxic
C. 1.5 mL is correct and delivers exactly 3 mg of Stadol, matching the provider's order. To calculate the correct volume to administer, use the formula: Dose to give= ordered dose/concentration= 3/2= 1.5ml
D. 0.9 mL would give 1.8 mg, which is below the ordered dose.

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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 reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?

Correct Answer is A

Explanation

The nurse is caring for a client in labor who has refused epidural anesthesia. An order was placed for Stadol 3mg IV Q4h PRN pain. The drug is supplied 2 mg per ml. How much of the medication should the nurse give?

Correct Answer is C

Explanation

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