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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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The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?
- A. 7.5.
- B. 7.4.
- C. 7.3.
- D. 7.2.
Correct Answer: D
Rationale: A fetal scalp blood pH below 7.2 indicates acidosis, suggesting fetal hypoxia and the need for intervention. Values above 7.25 are typically reassuring, and 7.2–7.25 may warrant close monitoring.
A primiparous client, 24 hours post-cesarean, reports incisional pain rated 6/10. The nurse should first:
- A. Administer prescribed analgesics.
- B. Encourage deep breathing exercises.
- C. Apply a warm compress to the incision.
- D. Assess the incision for signs of infection.
Correct Answer: A
Rationale: Administering analgesics addresses pain promptly, promoting comfort and mobility.
When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
- A. Oxytocin infusion solution.
- B. Disposable tongue blades.
- C. Portable ultrasound machine.
- D. Padding for the side rails.
Correct Answer: D
Rationale: Padding for the side rails is necessary to prevent injury during potential seizures.
When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?
- A. Return visit to the prenatal clinic in approximately 4 weeks.
- B. Decreased edema after 1 week of a low-protein, low-fiber diet.
- C. Bed rest on the left side during the day, with bathroom privileges.
- D. Immediate reporting of adverse reactions to magnesium sulfate therapy.
Correct Answer: C
Rationale: Bed rest on the left side enhances placental perfusion and reduces blood pressure.
A woman who has delivered a healthy newborn is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
- A. Bleeding that becomes lighter each day.
- B. Clots the size of golf balls.
- C. Saturating a pad in an hour.
- D. Lochia that last longer than 1 week.
Correct Answer: C
Rationale: Saturating a pad in an hour indicates excessive bleeding.