Question

FINAL PRACTICE 2

Question 31

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be:

A

Auscultating the fetal heart

B

Taking an obstetric history

C

Asking the client when she last ate

D

Ascertaining whether the membranes were ruptured

Question 32

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:

A

Not yet engaged

B

Entering the pelvic inlet

C

Below the ischial spines

D

Visible at the vaginal opening

Question 33

After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:

A

Above the umbilicus at the midline

B

Above the umbilicus on the left side

C

Below the umbilicus on the right side

D

Below the umbilicus near the left groin

Question 34

The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:

A

Until the time it is completely over

B

To the end of a second contraction

C

To the beginning of the next contraction

D

Until the time that the uterus becomes very firm

Question 35

The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:

A

Clear and dark amber in color

B

Milky, greenish yellow, containing shreds of mucus

C

Clear, almost colorless, and containing little white specks

D

Cloudy, greenish-yellow, and containing little white specks

Question 36

At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:

A

Discontinue the catheter, if the reading is not above 80%

B

Discontinue the catheter, if the reading does not go below 30%

C

Advance the catheter until the reading is above 90% and continue monitoring

D

Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

Question 37

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:

A

Stop the oxytocin infusion

B

Change the client’s position

C

Prepare for immediate delivery

D

Take the client’s blood pressure

Question 38

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

A

An acceleration

B

An early elevation

C

A sonographic motion

D

A tachycardic heart rate

Question 39

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:

A

Breech

B

Transverse

C

Occiput anterior

D

Occiput posterior

Question 40

The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is:

A

Blowing

B

Slow chest

C

Shallow

D

Accelerated-decelerated

Question 41

During the period of induction of labor, a client should be observed carefully for signs of:

A

Severe pain

B

Uterine tetany

C

Hypoglycemia

D

Umbilical cord prolapse

Question 42

A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:

A

Transfer her immediately by stretcher to the birthing unit

B

Tell her to breathe through her mouth and not to bear down

C

Instruct the client to pant during contractions and to breathe through her mouth

D

Support the perineum with the hand to prevent tearing and tell the client to pant

Question 43

A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she:

A

Will not feel the episiotomy

B

May lose bladder sensation

C

May lose the ability to push

D

Will no longer feel contractions

Question 44

Which of the following observations indicates fetal distress?

A

Fetal scalp pH of 7.14

B

Fetal heart rate of 144 beats/minute

C

Acceleration of fetal heart rate with contractions

D

Presence of long term variability

Question 45

Which of the following fetal positions is most favorable for birth?

A

Vertex presentation

B

Transverse lie

C

Frank breech presentation

D

Posterior position of the fetal head

Question 46

A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor?

A

Gender of the fetus

B

Fetal position

C

Labor progress

D

Oxygenation

Question 47

A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?

A

Preparatory phase

B

Latent phase

C

Active phase

D

Transition phase

Question 48

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?

A

Let the client get up to use the potty

B

Allow the client to use a bedpan

C

Perform a pelvic examination

D

Check the fetal heart rate

Question 49

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?

A

Contractions, passageway, placental position and function, pattern of care

B

Contractions, maternal response, placental position, psychological response

C

Passageway, contractions, placental position and function, psychological response

D

Passageway, placental position and function, paternal response, psychological response

Question 50

Fetal presentation refers to which of the following descriptions?

A

Fetal body part that enters the maternal pelvis first

B

Relationship of the presenting part to the maternal pelvis

C

Relationship of the long axis of the fetus to the long axis of the mother

D

A classification according to the fetal part

Question 51

A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?

A

Hysteria compounded by the flu

B

Placental abruption

C

Uterine rupture

D

Dysfunctional labor

Question 52

Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data?

A

Fetal presenting part is 1 cm above the ischial spines

B

Effacement is 4 cm from completion

C

Dilation is 50% completed

D

Fetus has achieved passage through the ischial spines

Question 53

Which of the following findings meets the criteria of a reassuring FHR pattern?

A

FHR does not change as a result of fetal activity

B

Average baseline rate ranges between 100 – 140 BPM

C

Mild late deceleration patterns occur with some contractions

D

Variability averages between 6 – 10 BPM

Question 54

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

A

Change the woman’s position

B

Stop the Pitocin

C

Elevate the woman’s legs

D

Administer oxygen via a tight mask at 8 to 10 liters/minute

Question 55

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:

A

Severe postpartum headache

B

Limited perception of bladder fullness

C

Increase in respiratory rate

D

Hypotension

Question 56

Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

A

Uses soap and warm water to wash the vulva and perineum

B

Washes from symphysis pubis back to episiotomy

C

Changes her perineal pad every 2 – 3 hours

D

Uses the peribottle to rinse upward into her vulva

Question 57

Which measure would be least effective in preventing postpartum hemorrhage?

A

Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

B

Encourage the woman to void every 2 hours

C

Massage the fundus every hour for the first 24 hours following birth

D

Teach the woman the importance of rest and nutrition to enhance healing

Question 58

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:

A

Express a strong need to review events and her behavior during the process of labor and birth

B

Exhibit a reduced attention span, limiting readiness to learn

C

Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn

D

Have reestablished her role as a spouse/partner

Question 59

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:

A

Tell the woman she can rest after she feeds her baby

B

Recognize this as a behavior of the taking-hold stage

C

Record the behavior as ineffective maternal-newborn attachment

D

Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Question 60

Parents can facilitate the adjustment of their other children to a new baby by:

Having the children choose or make a gift to give to the new baby upon its arrival home

B

Emphasizing activities that keep the new baby and other children together

C

Having the mother carry the new baby into the home so she can show the other children the new baby

Reducing stress on other children by limiting their involvement in the care of the new baby

NO PHOTOS PLEASE THANKS

Answer 1

QUESTIONS AND ANSWERS WITH RATIONALE

Question 31:

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be:

A.Auscultating the fetal heart

B.Taking an obstetric history

C.Asking the client when she last ate

D.Ascertaining whether the membranes were ruptured

Answer:

A.Auscultating the fetal heart

Rationale:

Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating. immediate intervention is required.

Question 32:

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:

A.Not yet engaged

B.Entering the pelvic inlet

C.Below the ischial spines

D.Visible at the opening

Answer:

C.Below the ischial spines

Rationale:

Positive numbers are used when a baby has descended beyond the ischial spines. During birth, a baby is at the +4 to +5 station. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

Question 33

After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:

A.Above the umbilicus at the midline

B.Above the umbilicus on the left side

C.Below the umbilicus on the right side

D.Below the umbilicus near the left groin

Answer:

C. Below the umbilicus on the right side

Rationale:

Fetal back is located in the right, where FHT is auscultated. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting). The back would be below the umbilicus and on the right side.

Question 34

The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:

A.Until the time it is completely over

B.To the end of a second contraction

C.To the beginning of the next contraction

D.Until the time that the uterus becomes very firm

Answer:

C.To the beginning of the next contraction

Rationale:

This is the way to determine the frequency of the contractions

Question 35

The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:

A.Clear and dark amber in color

B.Milky, greenish yellow, containing shreds of mucus

C.Clear, almost colorless, and containing little white specks

D.Cloudy, greenish-yellow, and containing little white specks

Answer:

C.Clear, almost colorless, and containing little white specks

Rationale:

By 36 weeks gestation. normal amniotic fluid is colorless with small particles of vernix caseosa present.

Question 36

At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:

A.Discontinue the catheter, if the reading is not above 80%

B.Discontinue the catheter, if the reading does not go below 30%

C.Advance the catheter until the reading is above 90% and continue monitoring

D.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

Answer:

D.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

Rationale:

Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.

Question 37

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:

A.Stop the oxytocin infusion

B.Change the client’s position

C.Prepare for immediate delivery

D.Take the client’s blood pressure

Answer:

B.Change the client’s position

Rationale:

Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

Question 38

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

A.An acceleration

B.An early elevation

C.A sonographic motion

D.A tachycardic heart rate

Answer:

A.An acceleration

Rationale:

An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.

Question 39

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:

A.Breech

B.Transverse

C.Occiput anterior

D.Occiput posterior

Answer:

D.Occiput posterior

Rationale:

A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

Question 40

The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is:

A.Blowing

B.Slow chest

C.Shallow

D.Accelerated-decelerated

Answer:

A.Blowing

Rationale:

Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

Question 41

During the period of induction of labor, a client should be observed carefully for signs of:

A.Severe pain

B.Uterine tetany

C.Hypoglycemia

D.Umbilical cord prolapse

Answer:

B.Uterine tetany

Rationale:

Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.

Question 42

A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:

A.Transfer her immediately by stretcher to the birthing unit

B.Tell her to breathe through her mouth and not to bear down

C.Instruct the client to pant during contractions and to breathe through her mouth

D.Support the perineum with the hand to prevent tearing and tell the client to pant

Answer:

D.Support the perineum with the hand to prevent tearing and tell the client to pant

Rationale:

Gentle pressure is applied to the baby’s head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will be no birth canal lacerations. It is impossible to push and pant at the same time.

Question 43

A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she:

A.Will not feel the episiotomy

B.May lose bladder sensation

C.May lose the ability to push

D.Will no longer feel contractions

Answer:

A.Will not feel the episiotomy

Rationale:

A pudendal block provides anesthesia to the perineum.

Question 44

Which of the following observations indicates fetal distress?

A.Fetal scalp pH of 7.14

B.Fetal heart rate of 144 beats/minute

C.Acceleration of fetal heart rate with contractions

D.Presence of long term variability

Answer:

A.Fetal scalp pH of 7.14

Rationale:

A fetal scalp pH below 7.25 indicates acidosis and fetal hypoxia.

Question 45

Which of the following fetal positions is most favorable for birth?

A.Vertex presentation

B.Transverse lie

C.Frank breech presentation

D.Posterior position of the fetal head

Answer:

A.Vertex presentation

Rationale:

Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie is an unacceptable fetal position for normal birth and requires a C-section. Frank breech presentation, in which the buttocks present first, can be a difficult normal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis.

Question 46

A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor?

A.Gender of the fetus

B.Fetal position

C.Labor progress

D.Oxygenation

Answer:

D.Oxygenation

Rationale:

Oxygenation of the fetus may be indirectly assessed through fetal monitoring by closely examining the fetal heart rate strip. Accelerations in the fetal heart rate strip indicate good oxygenation, while decelerations in the fetal heart rate sometimes indicate poor fetal oxygenation.

Question 47

A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?

A.Preparatory phase

B.Latent phase

C.Active phase

D.Transition phase

Answer:

C.Active phase

Rationale:

Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid cervical dilation begins. Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.

Question 48

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?

A.Let the client get up to use the potty

B.Allow the client to use a bedpan

C.Perform a pelvic examination

D.Check the fetal heart rate

Answer:

C.Perform a pelvic examination

Rationale:

A complaint of rectal pressure usually indicates a low presenting fetal part, signaling imminent delivery. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part.

Question 49

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?

A.Contractions, passageway, placental position and function, pattern of care

B.Contractions, maternal response, placental position, psychological response

C.Passageway, contractions, placental position and function, psychological response

D.Passageway, placental position and function, paternal response, psychological response

Answer:

C.Passageway, contractions, placental position and function, psychological response

Rationale:

The five essential factors (5 P’s) are passenger (fetus), passageway (pelvis), powers (contractions), placental position and function, and psyche (psychological response of the mother).

Question 50

Fetal presentation refers to which of the following descriptions?

A.Fetal body part that enters the maternal pelvis first

B.Relationship of the presenting part to the maternal pelvis

C.Relationship of the long axis of the fetus to the long axis of the mother

D.A classification according to the fetal part

Answer:

A.Fetal body part that enters the maternal pelvis first

Rationale:

Presentation is the fetal body part that enters the pelvis first; it’s classified by the presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. The relationship of the presenting fetal part to the maternal pelvis refers to fetal position. The relationship of the long axis to the fetus to the long axis of the mother refers to fetal lie; the three possible lies are longitudinal, transverse, and oblique.

Question 51

A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?

A.Hysteria compounded by the flu

B.Placental abruption

C.Uterine rupture

D.Dysfunctional labor

Answer:

C.Uterine rupture

Rationale:

Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client typically complains of bleeding and constant abdominal pain.

Question 52

Upon completion of a examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data?

A.Fetal presenting part is 1 cm above the ischial spines

B.Effacement is 4 cm from completion

C.Dilation is 50% completed

D.Fetus has achieved passage through the ischial spines

Answer:

A.Fetal presenting part is 1 cm above the ischial spines

Rationale:

Station of – 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Passage through the ischial spines with internal rotation would be indicated by a plus station, such as + 1. Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation.

Question 53

Which of the following findings meets the criteria of a reassuring FHR pattern?

A.FHR does not change as a result of fetal activity

B.Average baseline rate ranges between 100 – 140 BPM

C.Mild late deceleration patterns occur with some contractions

D.Variability averages between 6 – 10 BPM

Answer:

D.Variability averages between 6 – 10 BPM

Rationale:

Variability indicates a well oxygenated fetus with a functioning autonomic nervous system. FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats per minute. Late deceleration patterns are never reassuring, though early and mild variable decelerations are expected, reassuring findings.

Question 54

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

A.Change the woman’s position

B.Stop the Pitocin

C.Elevate the woman’s legs

D.Administer oxygen via a tight mask at 8 to 10 liters/minute

Answer:

B.Stop the Pitocin

Rationale:

Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic which stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

Question 55

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:

A.Severe postpartum headache

B.Limited perception of bladder fullness

C.Increase in respiratory rate

D.Hypotension

Answer:

D.Hypotension

Rationale:

Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia; 2 is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication.

Question 56

Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

A.Uses soap and warm water to wash the vulva and perineum

B.Washes from symphysis pubis back to episiotomy

C.Changes her perineal pad every 2 – 3 hours

D.Uses the peribottle to rinse upward into her vulva

Answer:

D.Uses the peribottle to rinse upward into her vulva

Rationale:

Responses 1, 2, and 3 are all appropriate measures. The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the birth canal since debris would be forced upward into the uterus through the still-open cervix.

Question 57

Which measure would be least effective in preventing postpartum hemorrhage?

A.Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

B.Encourage the woman to void every 2 hours

C.Massage the fundus every hour for the first 24 hours following birth

D.Teach the woman the importance of rest and nutrition to enhance healing

Answer:

C.Massage the fundus every hour for the first 24 hours following birth

Rationale:

The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

Question 58

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:

A.Express a strong need to review events and her behavior during the process of labor and birth

B.Exhibit a reduced attention span, limiting readiness to learn

C.Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn

D.Have reestablished her role as a spouse/partner

Answer:

C.Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn

Rationale:

One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Question 59

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:

A.Tell the woman she can rest after she feeds her baby

B.Recognize this as a behavior of the taking-hold stage

C.Record the behavior as ineffective maternal-newborn attachment

D.Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Answer:

D.Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Rationale:

Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

Question 60

Parents can facilitate the adjustment of their other children to a new baby by:

A.Having the children choose or make a gift to give to the new baby upon its arrival home

B.Emphasizing activities that keep the new baby and other children together

C.Having the mother carry the new baby into the home so she can show the other children the new baby

D.Reducing stress on other children by limiting their involvement in the care of the new baby

Answer:

A.Having the children choose or make a gift to give to the new baby upon its arrival home

Rationale:

Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.