Nokea
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
- A. Taking in.
- B. Taking on.
- C. Taking hold.
- D. Letting go.
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.
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A client asks about the benefits of breastfeeding for contraception. Which of the following responses by the nurse is most accurate?
- A. Breastfeeding is a reliable contraceptive method for the first year postpartum.
- B. The lactational amenorrhea method is effective only if the client is exclusively breastfeeding and amenorrheic.
- C. Breastfeeding prevents ovulation permanently while nursing.
- D. Breastfeeding is equally effective whether the client supplements with formula.
Correct Answer: B
Rationale: The lactational amenorrhea method (LAM) is effective for up to 6 months postpartum if the client is exclusively breastfeeding, amenorrheic, and the infant is under 6 months. It is not reliable for a year, does not permanently prevent ovulation, and is less effective with formula supplementation.
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in the neonate?
- A. Anemia.
- B. Hypoglycemia.
- C. Delayed meconium.
- D. Elevated bilirubin.
Correct Answer: B
Rationale: Large-for-gestational-age neonates (e.g., 4,082 g) are at risk for hypoglycemia due to increased metabolic demand and potential maternal diabetes. Hypoglycemia screening is a priority. Anemia, delayed meconium, or hyperbilirubinemia are less immediate.
Which of the following indicates successful latch-on during a breast-feeding session?
- A. Neonate's lips are flanged outward.
- B. Mother reports sharp pain throughout feeding.
- C. Neonate's cheeks are dimpled.
- D. Mother hears clicking sounds during sucking.
Correct Answer: A
Rationale: Flanged lips indicate a proper latch, ensuring effective milk transfer and preventing nipple trauma.
A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 reflexes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will first include:
- A. Administration of glucocorticoids(Betamethasone).
- B. Vaginal or cesarean delivery of the fetus.
- C. Prevention of seizures with phenytoin (Dilantin).
- D. Reduction of fluid retention with thiazides.
Correct Answer: B
Rationale: Delivery is the definitive treatment for severe preeclampsia.
A primiparous client diagnosed with cystitis at LIM 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breast-feed my baby?" The nurse should tell the client:
- A. You can continue to breast-feed as long as you want to do so.
- B. Alternate your breast-feeding with formula feeding to help you rest.
- C. You'll need to discontinue breast-feeding until the antibiotic therapy is stopped.
- D. You'll need to modify your technique by manually pumping your breasts.
Correct Answer: A
Rationale: Ampicillin is generally safe for breastfeeding, allowing the client to continue without interruption.