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 B

Explanation

The correct answer is B. Position the client with one hip elevated.

A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.

B. Positioning the client with one hip elevated is the priority action.

The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.

C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.

D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.

A. Determine respiratory function. B. Increase the TV fluid rate. C. Access emergency medications from cart D. Collect a maternal blood sample for coagulopathy studies

Correct Answer is A

Explanation

The correct answer is A.

A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.

B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.

C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.

D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.

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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

Correct Answer is B

Explanation

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply)

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A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

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A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?