Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?
A. She did her perineal care independently.
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
B. She is eager to talk about her birth experience.
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
C. She has not asked for anything for pain all day.
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
D. She sits and rocks her infant for long intervals.
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice A. She did her perineal care independently.
Choice A rationale:
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
Choice B rationale:
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
Choice C rationale:
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
Choice D rationale:
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
Similar Questions
A nurse is assessing a postpartum woman.
Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?
A. She did her perineal care independently.
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
B. She is eager to talk about her birth experience.
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
C. She has not asked for anything for pain all day.
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
D. She sits and rocks her infant for long intervals.
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
Full Explanation
The correct answer is choice A. She did her perineal care independently.
Choice A rationale:
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
Choice B rationale:
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
Choice C rationale:
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
Choice D rationale:
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth.
The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?
A. Between 24 and 28 weeks' gestation.
The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.
B. Between 8 and 12 weeks' gestation.
This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.
C. Between 15 and 19 weeks' gestation.
This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.
D. Between 30 and 32 weeks' gestation.
This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.
Full Explanation
The correct answer is choice A.
Choice A rationale:
The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.
Choice B rationale:
This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.
Choice C rationale:
This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.
Choice D rationale:
This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?
A. The cervix is effaced 1 cm.
The term “-1” in a vaginal examination does not refer to the effacement of the cervix. Effacement is usually expressed as a percentage.
B. The presenting part is 1 cm above the ischial spines.
In a vaginal examination, “-1” refers to the station of the fetus. A “-1” station means that the presenting part of the fetus (usually the head) is 1 cm above the ischial spines.
C. The cervix is 1 cm dilated.
The term “-1” in a vaginal examination does not refer to the dilation of the cervix. Dilation is usually measured in centimeters, from 0 (no dilation) to 10 (fully dilated).
D. The presenting part is 1 cm below the ischial spines.
A “-1” station does not mean that the presenting part is below the ischial spines. It means that it is above the ischial spines.
Full Explanation
The correct answer is choice B.
Choice A rationale:
The term “-1” in a vaginal examination does not refer to the effacement of the cervix. Effacement is usually expressed as a percentage.
Choice B rationale:
In a vaginal examination, “-1” refers to the station of the fetus. A “-1” station means that the presenting part of the fetus (usually the head) is 1 cm above the ischial spines.
Choice C rationale:
The term “-1” in a vaginal examination does not refer to the dilation of the cervix. Dilation is usually measured in centimeters, from 0 (no dilation) to 10 (fully dilated).
Choice D rationale:
A “-1” station does not mean that the presenting part is below the ischial spines. It means that it is above the ischial spines.