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 A
Explanation
Choice A rationale: Heavy menstrual bleeding after an IUD insertion can be a sign of complications such as displacement of the IUD, infection, or other issues that require medical attention. It's important for the client to come to the clinic as soon as possible to be evaluated by a healthcare provider and ensure everything is functioning properly.
Choice B rationale: Taking her temperature every 4 hours is not directly relevant to the concern of heavy menstrual bleeding unless there is a suspicion of infection, which should still be evaluated in the clinic.
Choice C rationale: While some spotting or light bleeding can be normal after IUD insertion, heavy menstrual bleeding is not typical and should be assessed by a healthcare provider to rule out complications.
Choice D rationale: Advising the client to change her method of birth control without a proper evaluation is not appropriate. A healthcare provider should determine if the IUD is the right method for her or if there are any issues that need to be addressed.
Correct Answer is D
Explanation
Choice A rationale
Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.
Choice B rationale
Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.
Choice C rationale
Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.
Choice D rationale
Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.
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