A nurse is assessing a postpartum woman.
Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?
She did her perineal care independently.
She is eager to talk about her birth experience.
She has not asked for anything for pain all day.
She sits and rocks her infant for long intervals.
The Correct Answer is A
The correct answer is choice A. She did her perineal care independently.
Choice A rationale:
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
Choice B rationale:
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
Choice C rationale:
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
Choice D rationale:
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.
Choice B rationale:
Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.
Choice C rationale:
Start of regular contractions is a sign of the onset of labor, not the end of the first stage.
Choice D rationale:
Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.
Correct Answer is ["A","E","F"]
Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
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