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, C, D, A

Explanation

B. Palpate the fundus to identify the fetal part. This step helps determine which part of the fetus is in the upper part of the uterus (fundus), usually the head or buttocks. C. Determine the location of the fetal back. This step involves palpating the sides of the abdomen to locate the fetal back, which feels firm and smooth, and the small parts (limbs), which feel irregular and knobby. D. Palpate for the fetal part presenting at the inlet. This step helps identify the part of the fetus that is above the pelvic inlet, usually the head or buttocks. A. Identify the attitude of the head. This final step involves determining the position and attitude of the fetal head,which helps assess the degree of flexion or extension.

A. Contractions that last 45 seconds each with a 3 min rest between contractions B. Contractions that last for 60 seconds each with a 3-min rest between contractions C. Contractions that last for 60 seconds each with a 4-min rest between contractions D. A contraction that lasts 4 min followed by a period of relaxation

Correct Answer is B

Explanation

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

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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

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