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 D
Explanation
Choice A rationale
Changing the dressing on a cesarean incision for a patient who is 1 day post-op requires sterile technique and assessment skills, which are beyond the scope of practice for assistive personnel (AP). This task should be performed by a licensed nurse.
Choice B rationale
Documenting the lochia amount on the perineal pad of a client who just transferred from labor and delivery involves assessment and documentation, which are nursing responsibilities. This task should not be delegated to AP.
Choice C rationale
Assessing an area of redness on the breast of a client who is 4 days postpartum requires clinical judgment and assessment skills, which are within the scope of practice for a licensed nurse. This task should not be delegated to AP.
Choice D rationale
Providing a sitz bath to a client who has a third-degree laceration and is 2 days postpartum is an appropriate task for AP. It is a comfort measure that does not require clinical judgment or assessment skills, making it suitable for delegation to AP.
Correct Answer is C
Explanation
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.