NUR 315 Exam 3 OB CH 18 Questions
with Complete Answers
6. During which phase of maternal adjustment will the mother relinquish the baby of
her fantasies and accept the real baby?
a. Letting-go
b. Taking-in
c. Taking-on
d. Taking-hold - ANSWER-ANS: A
Accepting the real infant and relinquishing the fantasy infant occurs during the
letting-go phase of maternal adjustment. In the taking-in phase, the mother is
primarily focused on her own needs. There is no taking-on phase of maternal
adjustment. During the taking-hold phase, the mother assumes responsibility for her
own care and shifts her attention to the infant.
PTS: 1 DIF: Cognitive Level: Understanding REF: 353
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity
7. A 25-year-old gravida 1, para 1, who had an emergency cesarean birth 3 days
ago is scheduled for discharge. As you prepare her for discharge, she begins to cry.
Which should be your initial action?
a. Assess her for pain.
b. Allow her time to express her feelings.
c. Point out how lucky she is to have a healthy baby.
d. Explain that she is experiencing postpartum blues. - ANSWER-ANS: B
Although many women experience transient postpartum blues, they need assistance
in expressing their feelings. Assessing her for pain assumes that she is in pain.
Pointing out how lucky she is to have a healthy baby is blocking communication. She
needs the opportunity to express her feelings first. Later, client teaching can occur.
PTS: 1 DIF: Cognitive Level: Application REF: 355
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
8. A husband calls the nurse's station stating that his wife, who delivered last week,
is happy one minute and crying the next. He says, "She was never like this before
the baby was born." Which should be the nurse's initial response?
a. Reassure him that this behavior is normal.
b. Advise him to get immediate psychological help for her.
c. Tell him to ignore the mood swings because they will go away.
d. Instruct him in the signs, symptoms, and duration of postpartum blues. -
ANSWER-ANS: A
Before providing further instructions, inform family members of the fact that
postpartum blues are a normal process to allay anxieties and increase receptiveness
to learning. Postpartum blues are a normal process that is short-lived; no medical
intervention is needed. Telling him to ignore the moods blocks communication and
may belittle the husband's concerns. Client teaching is important; however, his
anxieties need to be allayed before he will be receptive to teaching.
, PTS: 1 DIF: Cognitive Level: Application REF: 355
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
9. To promote bonding and attachment immediately after birth, which action should
the nurse take?
a. Assist the mother in feeding her baby.
b. Allow the mother quiet time with her infant.
c. Teach the mother about the concepts of bonding and attachment.
d. Assist the mother in assuming an en face position with her newborn. - ANSWER-
ANS: D
Assisting the mother in assuming an en face position with her newborn will support
the bonding process. After birth is a good time to initiate breastfeeding, but first the
mother needs time to explore the new infant and begin the bonding process. The
mother should be given as much privacy as possible; however, nursing assessments
must still be continued during this critical time. The mother has just delivered and is
more focused on the infant; she will not be receptive to teaching at this time.
PTS: 1 DIF: Cognitive Level: Application REF: 351, 363
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
10. While the nurse is demonstrating a baby bath, the client states, "The other nurse
told me to do it a different way." Which response should the nurse make?
a. Tell her to do the procedure whichever way works best for her.
b. Confront the other nurse about her knowledge of the procedure.
c. Reassure her that procedures are based on standard principles and may vary.
d. Tell her that the other nurse does not have much experience in caring for
newborns. - ANSWER-ANS: C
Procedures may vary as long as basic principles are included. There is no evidence
that the other nurse gave incorrect information. Telling her whichever way works best
or the other nurse does not have much experience do not answer her concerns.
PTS: 1 DIF: Cognitive Level: Application REF: 361
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
11. A new mother states, "My mother-in-law will be here from out of town for a few
weeks. I'm afraid she will take over the care of the baby." Which response should the
nurse make?
a. Tell the client that everything will be okay.
b. Tell the client how lucky she is to have someone to help her.
c. Encourage the client to allow her mother-in-law to take care of the newborn.
d. Encourage the client to tell her mother-in-law that she (the new mother) wants to
care for her infant. - ANSWER-ANS: D
Before the mother-in-law has the opportunity to take over, the mother needs to state
her own desire to care for the infant. Telling the client everything will be okay or she
is lucky does not address the client's concern and are dismissive. The new mother
needs to believe that she can care for her baby and should express this to the
mother-in-law so she will not feel resentful in the future.
PTS: 1 DIF: Cognitive Level: Application REF: 360
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
with Complete Answers
6. During which phase of maternal adjustment will the mother relinquish the baby of
her fantasies and accept the real baby?
a. Letting-go
b. Taking-in
c. Taking-on
d. Taking-hold - ANSWER-ANS: A
Accepting the real infant and relinquishing the fantasy infant occurs during the
letting-go phase of maternal adjustment. In the taking-in phase, the mother is
primarily focused on her own needs. There is no taking-on phase of maternal
adjustment. During the taking-hold phase, the mother assumes responsibility for her
own care and shifts her attention to the infant.
PTS: 1 DIF: Cognitive Level: Understanding REF: 353
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity
7. A 25-year-old gravida 1, para 1, who had an emergency cesarean birth 3 days
ago is scheduled for discharge. As you prepare her for discharge, she begins to cry.
Which should be your initial action?
a. Assess her for pain.
b. Allow her time to express her feelings.
c. Point out how lucky she is to have a healthy baby.
d. Explain that she is experiencing postpartum blues. - ANSWER-ANS: B
Although many women experience transient postpartum blues, they need assistance
in expressing their feelings. Assessing her for pain assumes that she is in pain.
Pointing out how lucky she is to have a healthy baby is blocking communication. She
needs the opportunity to express her feelings first. Later, client teaching can occur.
PTS: 1 DIF: Cognitive Level: Application REF: 355
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
8. A husband calls the nurse's station stating that his wife, who delivered last week,
is happy one minute and crying the next. He says, "She was never like this before
the baby was born." Which should be the nurse's initial response?
a. Reassure him that this behavior is normal.
b. Advise him to get immediate psychological help for her.
c. Tell him to ignore the mood swings because they will go away.
d. Instruct him in the signs, symptoms, and duration of postpartum blues. -
ANSWER-ANS: A
Before providing further instructions, inform family members of the fact that
postpartum blues are a normal process to allay anxieties and increase receptiveness
to learning. Postpartum blues are a normal process that is short-lived; no medical
intervention is needed. Telling him to ignore the moods blocks communication and
may belittle the husband's concerns. Client teaching is important; however, his
anxieties need to be allayed before he will be receptive to teaching.
, PTS: 1 DIF: Cognitive Level: Application REF: 355
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
9. To promote bonding and attachment immediately after birth, which action should
the nurse take?
a. Assist the mother in feeding her baby.
b. Allow the mother quiet time with her infant.
c. Teach the mother about the concepts of bonding and attachment.
d. Assist the mother in assuming an en face position with her newborn. - ANSWER-
ANS: D
Assisting the mother in assuming an en face position with her newborn will support
the bonding process. After birth is a good time to initiate breastfeeding, but first the
mother needs time to explore the new infant and begin the bonding process. The
mother should be given as much privacy as possible; however, nursing assessments
must still be continued during this critical time. The mother has just delivered and is
more focused on the infant; she will not be receptive to teaching at this time.
PTS: 1 DIF: Cognitive Level: Application REF: 351, 363
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
10. While the nurse is demonstrating a baby bath, the client states, "The other nurse
told me to do it a different way." Which response should the nurse make?
a. Tell her to do the procedure whichever way works best for her.
b. Confront the other nurse about her knowledge of the procedure.
c. Reassure her that procedures are based on standard principles and may vary.
d. Tell her that the other nurse does not have much experience in caring for
newborns. - ANSWER-ANS: C
Procedures may vary as long as basic principles are included. There is no evidence
that the other nurse gave incorrect information. Telling her whichever way works best
or the other nurse does not have much experience do not answer her concerns.
PTS: 1 DIF: Cognitive Level: Application REF: 361
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
11. A new mother states, "My mother-in-law will be here from out of town for a few
weeks. I'm afraid she will take over the care of the baby." Which response should the
nurse make?
a. Tell the client that everything will be okay.
b. Tell the client how lucky she is to have someone to help her.
c. Encourage the client to allow her mother-in-law to take care of the newborn.
d. Encourage the client to tell her mother-in-law that she (the new mother) wants to
care for her infant. - ANSWER-ANS: D
Before the mother-in-law has the opportunity to take over, the mother needs to state
her own desire to care for the infant. Telling the client everything will be okay or she
is lucky does not address the client's concern and are dismissive. The new mother
needs to believe that she can care for her baby and should express this to the
mother-in-law so she will not feel resentful in the future.
PTS: 1 DIF: Cognitive Level: Application REF: 360
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
