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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.
Choice B Reason:
Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.
Choice C Reason:
C. “A blood glucose of 130 to 140 is considered a positive screening result.”
In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.
.
Choice D Reason:
Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.
Correct Answer is A
Explanation
The correct answer is A. Cervical dilation.
A. Cervical dilation is a definitive sign of labor.
Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.
B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.
C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.
D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.
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