A nurse is caring for a client during delivery. What is a priority action of the nurse to promote parent-infant bonding immediately after delivery?
Teach the parents how to swaddle.
Position the infant on the client’s chest for skin-to-skin care.
Offer to take the newborn to the nursery so the parents may nap.
Assess the infant under the radiant warmer.
The Correct Answer is B
Choice A rationale
Teaching the parents how to swaddle is important for newborn care, but it is not the priority action immediately after delivery to promote parent-infant bonding. Skin-to-skin contact is more effective in establishing an initial bond.
Choice B rationale
Positioning the infant on the client’s chest for skin-to-skin care is the priority action to promote parent-infant bonding immediately after delivery. Skin-to-skin contact helps regulate the infant’s temperature, heart rate, and breathing, and promotes bonding through physical closeness and sensory interaction.
Choice C rationale
Offering to take the newborn to the nursery so the parents may nap is not the priority action for promoting bonding immediately after delivery. While rest is important, the initial moments after birth are crucial for establishing a bond through direct contact.
Choice D rationale
Assessing the infant under the radiant warmer is important for ensuring the infant’s health, but it is not the priority action for promoting parent-infant bonding immediately after delivery. Skin-to-skin contact should be prioritized unless there are medical concerns that require immediate attention. .
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Correct Answer is C
Explanation
Choice A rationale
Lack of appetite is not typically associated with the taking-in phase of maternal postpartum adjustment. During this phase, the mother is more focused on her own needs, such as rest and recovery from childbirth.
Choice B rationale
Eagerness to learn newborn care skills is more characteristic of the taking-hold phase, which follows the taking-in phase. In the taking-in phase, the mother is more passive and dependent, focusing on her own needs.
Choice C rationale
Discussion of the birth experience is a common behavior during the taking-in phase. The mother often wants to talk about her labor and delivery experience as a way to process and integrate the event.
Choice D rationale
Reconnection with her partner is not a primary focus during the taking-in phase. The mother is more focused on her own recovery and the immediate needs of her newborn.
Correct Answer is A
Explanation
Choice A rationale
The client is exhibiting expected assessment findings. Three days postpartum, it is normal for the fundus to be three fingerbreadths below the umbilicus, lochia rubra to be light, and the breasts to be full and warm to palpation without evidence of redness or pain. These findings indicate that the uterus is involuting properly, and the breasts are producing milk for breastfeeding.
Choice B rationale
The client is not exhibiting indications of mastitis. Mastitis is characterized by breast tenderness, redness, warmth, and pain, often accompanied by fever and flu-like symptoms. The absence of these symptoms suggests that the client does not have mastitis.
Choice C rationale
There is no indication that the client should be advised to remove her nursing bra. A well-fitting nursing bra can provide support and comfort during breastfeeding. The client should continue to wear a nursing bra as needed.
Choice D rationale
There is no indication that the client should be advised to stop breastfeeding. The assessment findings suggest that breastfeeding is going well, and the client should be encouraged to continue breastfeeding to provide optimal nutrition for the infant.