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
A macrosomic baby, or a baby with a high birth weight, can stretch the uterus significantly, increasing the risk of postpartum hemorrhage. The overstretched uterus may not contract effectively after birth, leading to excessive bleeding.
Choice B rationale
Uterine involution refers to the process of the uterus returning to its pre-pregnancy size. Effective uterine involution typically reduces the risk of hemorrhage, rather than increasing it, as the contracting uterus helps compress blood vessels and control bleeding.
Choice C rationale
A first-degree laceration is a minor perineal tear that typically heals without significant intervention. While it can cause some bleeding, it is usually not sufficient to lead to postpartum hemorrhage. More severe lacerations (third or fourth degree) pose higher risks.
Choice D rationale
Endometriosis is a condition where tissue similar to the lining inside the uterus grows outside it. It does not directly increase the risk of postpartum hemorrhage. The condition primarily causes pain and fertility issues rather than acute bleeding post-delivery.
Correct Answer is B
Explanation
Choice A rationale
Applying hot compresses to the breasts prior to feeding is not recommended for painful nipples due to breastfeeding. It may exacerbate pain and discomfort.
Choice B rationale
Teaching latching and releasing of suction techniques helps ensure that the baby latches correctly and releases properly from the breast, which can prevent and alleviate nipple pain and trauma.
Choice C rationale
Rubbing colostrum on the nipples after a feeding session is beneficial as colostrum has healing properties, but it does not address the immediate technique-related cause of painful nipples.
Choice D rationale
Air-drying nipples for 10 minutes at the end of the feeding session can be helpful for healing, but proper latching techniques are more effective in preventing nipple pain.
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