A nurse is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.)

Point out to the father that the newborn turns toward his voice.

Ask the father why he is concerned about bonding with the newborn.

Encourage the father to touch and stroke the newborn's skin.

Demonstrate diapering and swaddling techniques for the father.

Encourage the father to lay the newborn beside him while both are sleeping.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Pointing out to the father that the newborn turns toward his voice helps him understand that the baby is already responding to him, promoting bonding.

Choice B rationale:

Asking the father why he is concerned about bonding with the newborn allows the nurse to address specific fears or misconceptions and provide appropriate support.

Choice C rationale:

Encouraging the father to touch and stroke the newborn's skin promotes physical contact and enhances the bonding process.

Choice D rationale:

Demonstrating diapering and swaddling techniques for the father helps him feel more confident in caring for his baby and fosters bonding through caregiving activities.

Choice E rationale:

Encouraging the father to lay the newborn beside him while both are sleeping promotes skin- to-skin contact and allows for bonding during restful moments. However, the nurse should ensure that safety measures are followed to prevent accidental suffocation. By following these actions, the nurse can support the father's bonding with his newborn and facilitate a positive and nurturing parent-infant relationship.

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Correct Answer is A

Explanation

Choice A rationale:

The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.

Choice B rationale:

Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.

Choice C rationale:

Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.

Choice D rationale:

Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.

A. Prepare the equipment necessary to initiate an amnioinfusion. B. Administer oxygen at 10 L/min via a nonrebreather face mask. C. Discontinue the infusion of oxytocin. D. Place the client in a left lateral position.

Correct Answer is D

Explanation

Choice A reason:

Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

Choice B reason:

Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.

Choice C reason:

Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.

Choice D reason:

This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

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A nurse is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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