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 B
Explanation
Choice A Reason:
Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence
Choice B Reason:
Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.
Choice C Reason:
Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.
Choice D Reason:
Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.
Correct Answer is B
Explanation
The correct answer is B.
A. Place warm, moist packs on the breasts: Warm, moist packs can increase blood flow and may actually stimulate milk production. This is not an appropriate intervention for lactation suppression.
B. Apply cabbage leaves to the breasts: This is the correct intervention. Cabbage leaves have been traditionally used to help reduce engorgement and suppress lactation. The mechanism is not fully understood, but it is believed that compounds in cabbage may help decrease milk supply.
C. Wear a loose-fitting bra: Wearing a loose-fitting bra can help reduce friction and discomfort, but it is not a specific intervention for lactation suppression.
D. Put green teabags on the breast: Green teabags are not commonly recommended for lactation suppression. Cabbage leaves are more widely accepted for this purpose.
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