A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
Holding the newborn in an en face position
Asking the father to change the newborn's diaper
Viewing the newborn's actions to be uncooperative
Requesting the nurse take the newborn to the nursery so she can rest
The Correct Answer is C
A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.
B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.
C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding
infant cues, requiring the nurse's intervention.
D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.
Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.
B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.
C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.
D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.
Correct Answer is D
Explanation
A. Strong contractions are expected with oxytocin augmentation and do not require a decrease in the infusion rate.
B. A cervical dilation rate of 1 cm every 4 hours is slow but does not indicate the need to decrease oxytocin.
C. Contractions lasting 80 seconds are prolonged but do not necessarily indicate hyperstimulation.
D. Contractions occurring every 90 seconds suggest uterine tachysystole, which can compromise fetal oxygenation and requires a decrease in the oxytocin infusion rate.
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