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 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.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
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