A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Discuss contraceptive options with the client and her partner.

Repeat information to ensure client understanding.

Listen to the client and her partner as they reflect upon the birth experience.

Demonstrate to the client how to perform a newborn bath

Answer and Explanation

The Correct Answer is D

A. Discuss contraceptive options with the client and her partner. Discussing contraceptive options typically occurs later in the postpartum period, often during follow-up visits. This is not a priority during the early taking-hold phase, when the mother is focused on learning to care for herself and her baby.

B. Repeat information to ensure client understanding. Repeating information and ensuring understanding is more critical during the taking-in phase, which occurs in the first 24 to 48 hours postpartum, when the mother is more passive, fatigued, and focused on her own recovery. In the taking-hold phase, the mother is typically more alert and eager to learn.

C. Listen to the client and her partner as they reflect upon the birth experience. Reflecting on the birth experience is more aligned with the taking-in phase, when the mother is focused on herself and may need emotional support in processing the experience.

D. Demonstrate to the client how to perform a newborn bath. In the taking-hold phase, the mother is ready to take responsibility for the care of her newborn and actively seeks guidance. Demonstrating how to bathe the newborn is an appropriate intervention, as it provides practical support and helps the mother gain confidence in newborn care.

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Correct Answer is A

Explanation

The correct answer is A. Emotional lability.

A. Emotional lability: Emotional lability refers to rapid and unpredictable changes in mood, with intense emotions shifting quickly from one extreme to another. It is a common aspect of the emotional adaptation to pregnancy and is often influenced by hormonal changes.

B. Focusing phase: The focusing phase is a concept related to the process of adapting to pregnancy. It involves the pregnant individual focusing on the reality of the pregnancy and incorporating the changes into their self-concept. While mood changes may occur during this phase, the client's statement more specifically reflects emotional lability.

C. Cognitive restructuring: Cognitive restructuring involves changing thought patterns to modify emotional responses. The client's statement does not necessarily indicate a deliberate process of changing thought patterns but rather describes the emotional swings often associated with pregnancy.

D. Couvade syndrome: Couvade syndrome refers to a phenomenon where a partner experiences symptoms that mimic pregnancy symptoms. It is not applicable in this context as the client is describing her own emotional experiences related to pregnancy.

A. Confirm the newborn's Apgar score B. Verify the newborn's identification. C. Administer vitamin K to the newborn. D. Determine obstetrical risk factors.

Correct Answer is B

Explanation

Choice A Reason:

Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.

Choice B Reason:

Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.

Choice C Reason:

Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.

Choice D Reason:

Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.

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A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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