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. When the cervix is fully dilated.
Choice A rationale:
The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.
Choice B rationale:
Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.
Choice C rationale:
The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.
Choice D rationale:
The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Brownish vaginal discharge can be a sign of labor but it is not definitive.
Choice B rationale:
Cervical dilation is a definitive sign that labor has started.
Choice C rationale:
Presence of amniotic fluid in the vaginal vault can indicate rupture of membranes but it does not confirm labor.
Choice D rationale:
Pain above the umbilicus is not a typical sign of labor.
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