The nurse is assessing the client's transition to the taking-hold phase after an uncomplicated vaginal birth.
Which behavior by the mother best indicates this transition is occurring?
Focuses primarily on her own needs.
Is very excited and talkative about the birth experience.
Is interested in learning more about infant care.
Relies on nursing staff for assistance.
The Correct Answer is C
Choice A rationale
Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.
Choice B rationale
Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.
Choice C rationale
Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.
Choice D rationale
Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While burping is important after feeding to prevent discomfort and regurgitation, it does not directly indicate overall health or hydration status.
Choice B rationale
Frequent loose yellow stools are typical in breastfed infants and indicate proper digestion and nutrition, but do not address overall hydration status directly.
Choice C rationale
Steady weight gain indicates good nutrition and overall health in the infant, reflecting adequate feeding and hydration.
Choice D rationale
Sleeping through the night is not an expectation for newborns, as they typically need frequent feeding due to small stomach capacity and rapid growth needs.
Correct Answer is B
Explanation
Choice A rationale
If the client and the newborn are both Rh positive, Rh immunoglobulin is not necessary because there is no Rh incompatibility.
Choice B rationale
Rh immunoglobulin is administered when the mother is Rh negative and the newborn is Rh positive to prevent the mother's immune system from developing antibodies against Rh-positive blood.
Choice C rationale
If the client is Rh positive and the newborn is Rh negative, Rh immunoglobulin is not needed because Rh incompatibility does not occur in this scenario.
Choice D rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, so Rh immunoglobulin is not needed.
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