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NR-330 2023 EXAM QUESTIONS WITH


ANSWERS (A+ GRADED)
After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to

the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for

impaired parenting related to deficient knowledge of newborn care. In planning for the

woman’s discharge, what should the nurse be certain to include in the plan of care?

a. Instruct the patient how to feed and bathe her infant.

b. Give the patient written information on bathing her infant.

c. Advise the patient that all mothers instinctively know how to care for their infants.

Provide time for the patient to bathe her infant after she views an infant bath
d.
demonstration.

ANS: D

Having the mother demonstrate infant care is a valuable method of assessing the client’s

understanding of her newly acquired knowledge, especially in this age group, because she

may inadvertently neglect her child. Although verbalizing how to care for the infant is a form

of patient education, it is not the most developmentally appropriate teaching for a teenage

mother. Advising the patient that all mothers instinctively know how to care for their infants

is an inappropriate statement; it is belittling and false.


PTS: 1 DIF: Cognitive Level: Application REF: 523

OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Health Promotion and Maintenance

1. The nurse observes several interactions between a postpartum woman and her new

son.What behavior, if exhibited by this woman, would the nurse identify as a possible

maladaptive behavior regarding parent-infant attachment?

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a. Talks and coos to her son

b. Seldom makes eye contact with her son

c. Cuddles her son close to her

d. Tells visitors how well her son is feeding

ANS: B

The woman should be encouraged to hold her infant in the en face position and make eye

contact with the infant. Normal infant-parent interactions include talking and cooing to her

son, cuddling her son close to her, and telling visitors how well her son is feeding.
PTS: 1 DIF: Cognitive Level: Application REF: 524

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Psychosocial Integrity

2. The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy

thatthe nurse can use to facilitate mother-infant attachment in this mother is to:

a. Tell the mother she must pay attention to her infant.

b. Show the mother how the infant initiates interaction and pays attention to her.

c. Demonstrate for the mother different positions for holding her infant while feeding.

d. Arrange for the mother to watch a video on parent-infant interaction.

ANS: B

Pointing out the responsiveness of the infant is a positive strategy for facilitating

parent-infant attachment. Telling the mother that she must pay attention to her infant may be

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perceived as derogatory and is not appropriate. Educating the young mother in infant care is

important; however, pointing out the responsiveness of her baby is a better tool for

facilitating mother-infant attachment. Videos are an educational tool that can demonstrate

parent-infant attachment, but encouraging the mother to recognize the infant’s responsiveness

is more appropriate.
PTS: 1 DIF: Cognitive Level: Application REF: 516

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. The nurse hears a primiparous woman talking to her son and telling him that his chin

is justlike his dad’s chin. This woman’s statement reflects:

a. Mutuality. c. Claiming.

b. Synchrony. d. Reciprocity.

ANS: C

Claiming refers to the process by which the child is identified in terms of likeness to other

family members. Mutuality occurs when the infant’s behaviors and characteristics call forth a

corresponding set of maternal behaviors and characteristics. Synchrony refers to the “fit”

between the infant’s cues and the parent’s responses. Reciprocity is a type of body movement

or behavior that provides the observer with cues.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 511

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

4. New parents express concern that, because of the mother’s emergency cesarean birth

undergeneral anesthesia, they did not have the opportunity to hold and bond with their

daughter immediately after her birth. The nurse’s response should convey to the parents

that:

Attachment, or bonding, is a process that occurs over time and does not require early
a.
contact.

b. The time immediately after birth is a critical period for people.

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c. Early contact is essential for optimum parent-infant relationships.

d. They should just be happy that the infant is healthy.

ANS: A

Attachment, or bonding, is a process that occurs over time and does not require early contact.

The formerly accepted definition of bonding held that the period immediately after birth was

a critical time for bonding to occur. Research since has indicated that parent-infant

attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment

involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A

response that conveys that the parents should just be happy that the infant is healthy is

inappropriate because it is derogatory and belittling.


PTS: 1 DIF: Cognitive Level: Application REF: 513

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

5. During a phone follow-up conversation with a woman who is 4 days’ postpartum,

the woman tells the nurse, “I don’t know what’s wrong. I love my son, but I feel so let

down. Iseem to cry for no reason!” The nurse would recognize that the woman is

experiencing:

a. Taking-in. c. Postpartum (PP) blues.

b. Postpartum depression (PPD). d. Attachment difficulty.

ANS: C

During the PP blues women are emotionally labile, often crying easily and for no apparent

reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period

after birth when the mother focuses on her own psychologic needs. Typically this period lasts

24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is

more serious and persistent than the PP blues. Crying is not a maladaptive attachment

response; it indicates PP blues.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 517

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Psychosocial Integrity

6. The nurse can help a father in his transition to parenthood by:

a. Pointing out that the infant turned at the sound of his voice.

b. Encouraging him to go home to get some sleep.

c. Telling him to tape the infant’s diaper a different way.

d. Suggesting that he let the infant sleep in the bassinet.

ANS: A

Infants respond to the sound of voices. Because attachment involves a reciprocal interchange,

observing the interaction between parent and infant is very important. Separation of the

parent and infant does not encourage parent-infant attachment. Educating the parent in infant

care techniques is important; however, the manner in which a diaper is taped is not relevant

and does not enhance parent-infant interactions.

Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a

father to want to hold the infant as the baby sleeps.


PTS: 1 DIF: Cognitive Level: Application REF: 515

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

7. The nurse notes that a Vietnamese woman does not cuddle or interact with her

newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In

evaluatingthe woman’s behavior with her infant, the nurse realizes that:

What appears to be a lack of interest in the newborn is in fact the Vietnamese way of
a.
demonstrating intense love by attempting to ward off evil spirits.

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b. The woman is inexperienced in caring for newborns.

The woman needs a referral to a social worker for further evaluation of her parenting
c.
behaviors once she goes home with the newborn.

d. Extra time needs to be planned for assisting the woman in bonding with her newborn.

ANS: A

The nurse may observe a Vietnamese woman who gives minimal care to her infant and

refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is

this cultural group’s attempt to ward off evil spirits and actually reflects an intense love and

concern for the infant. It is important to educate the woman in infant care, but it is equally

important to acknowledge her cultural beliefs and practices.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 523

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

8. Many first-time parents do not plan on their parents’ help immediately after the

newbornarrives. What statement by the nurse is the most appropriate when counseling

new parents about the involvement of grandparents?

a. “You should tell your parents to leave you alone.”

“Grandparents can help you with parenting skills and also help preserve family
b.
traditions.”

c. “Grandparent involvement can be very disruptive to the family.”

d. “They are getting old. You should let them be involved while they can.”

ANS: B

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“Grandparents can help you with parenting skills and also help preserve family traditions” is

the most appropriate response. Intergenerational help may be perceived as interference;

however, a statement of this sort is not therapeutic to the adaptation of the family. Not only is

“Grandparent involvement can be very disruptive to the family” invalid, it also is not an

appropriate nursing response. Regardless of age, grandparents can help with parenting skills

and preserve family traditions. Talking about the age of the grandparents is not the most

appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.
PTS: 1 DIF: Cognitive Level: Analysis REF: 526

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

9. When the infant’s behaviors and characteristics call forth a corresponding set of maternal

behaviors and characteristics, this is called:

a. Mutuality. c. Claiming.

b. Bonding. d. Acquaintance.

ANS: A

Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding

is the process over time of parents forming an emotional attachment to their infant. Mutuality

refers to a shared set of behaviors that is a part of the bonding process.

Claiming is the process by which parents identify their new baby in terms of likeness to other

family members and their differences and uniqueness. Like mutuality, acquaintance is part of

attachment. It describes how parents get to know their baby during the immediate postpartum

period through eye contact, touching, and talking.


PTS: 1 DIF: Cognitive Level: Knowledge REF: 510

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

10. In follow-up appointments or visits with parents and their new baby, it may be

useful ifthe nurse can identify parental behaviors that can either facilitate or inhibit

attachment. Which one is a facilitating behavior?

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a. The parents have difficulty naming the infant.

b. The parents hover around the infant, directing attention to and pointing at the infant.

c. The parents make no effort to interpret the actions or needs of the infant.

d. The parents do not move from fingertip touch to palmar contact and holding.

ANS: B

Hovering over the infant and obviously paying attention to the baby are facilitating behaviors.

Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the

actions or needs of the infant, and not moving from fingertip touch to palmar contact and

holding.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 511

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. With regard to parents’ early and extended contact with their infant and the

relationshipsbuilt, nurses should be aware that:

a. Immediate contact is essential for the parent-child relationship.

b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket.

Extended contact is especially important for adolescents and low-income women


c.
because they are at risk for parenting inadequacies.

d. Mothers need to take precedence over their partners and other family matters.

ANS: C

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Nurses should encourage any activity that optimizes family extended contact. Immediate

contact facilitates the attachment process but is not essential; otherwise, adopted infants

would not establish the affectionate ties they do. The mode of infant-mother contact does not

appear to have any important effect. Mothers and their partners are considered equally

important.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 514

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

12. In the United States the en face position is preferred immediately after birth. Nurses

canfacilitate this process by all of these actions except:

a. Washing both the infant’s face and the mother’s face.

b. Placing the infant on the mother’s abdomen or breast with their heads on the same plane.

c. Dimming the lights.

d. Delaying the instillation of prophylactic antibiotic ointment in the infant’s eyes.

ANS: A

To facilitate the position in which the parent’s and infant’s faces are approximately 8 inches

apart on the same plane, allowing them to make eye contact, the nurse can place the infant at

the proper height on the mother’s body, dim the light so that the infant’s eyes open, and delay

putting ointment in the infant’s eyes.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 514

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

13. Other early sensual contacts between infant and mother involve sound and smell.

Nursesshould be aware that, despite what folk wisdom may say:

a. High-pitched voices irritate newborns.

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b. Infants can learn to distinguish their mother’s voice from others soon after birth.

c. All babies in the hospital smell alike.

d. A mother’s breast milk has no distinctive odor.

ANS: B

Infants know the sound of their mother’s voice early. Infants respond positively to

high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the

odor of their mother’s breast milk.


PTS: 1 DIF: Cognitive Level: Knowledge REF: 515

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

14. After they are born, a crying infant may be soothed by being held in a position in

whichthe newborn can hear the mother’s heartbeat. This phenomenon is known as:

a. Entrainment. c. Synchrony.

b. Reciprocity. d. Biorhythmicity.

ANS: D

The newborn is in rhythm with the mother. The infant develops a personal biorhythm with

the parents’ help over time. Entrainment is the movement of newborns in time to the structure

of adult speech. Reciprocity is body movement or behavior that gives cues to the person’s

desires. These take several weeks to develop with a new baby. Synchrony is the fit between

the infant’s behavioral cues and the parent’s responses.


PTS: 1 DIF: Cognitive Level: Knowledge REF: 515

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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15. Of the many factors that influence parental responses, nurses should be conscious of

negative stereotypes that apply to specific patient populations. Which response could be

aninappropriate stereotype of adolescent mothers?

An adolescent mother’s egocentricity and unmet developmental needs interfere with her
a.
ability to parent effectively.

An adolescent mother is likely to use less verbal instruction, be less responsive, and
b.
interact less positively than other mothers.

c. Adolescent mothers have a higher documented incidence of child abuse.

Mothers older than 35 often deal with more stress related to work and career issues and
d.
decreasing libido.

ANS: C

Adolescent mothers are more inclined to have a number of parenting difficulties that benefit

from counseling; however, a higher incidence of child abuse is not one of them. Midlife

mothers have many competencies, but they are more likely to have to deal with career issues

and the accompanying stress.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 521

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

16. When working with parents who have some form of sensory

impairment, nurses shouldunderstand that is an inaccurate statement.

One of the major difficulties visually impaired parents experience is the skepticism of
a.
health care professionals.

b. Visually impaired mothers cannot overcome the infant’s need for eye-to-eye contact.

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The best approach for the nurse is to assess the parents’ capabilities rather than focusing
c.
on their disabilities.

Technologic advances, including the Internet, can provide deaf parents with a full range
d.
of parenting activities and information.

ANS: B

Other sensory output can be provided by the parent, other people can participate, and other

coping devices can be used. The skepticism, open or hidden, of health care professionals

places an additional and unneeded hurdle for the parents. After the parents’ capabilities have

been assessed (including some the nurse may not have expected), the nurse can help find

ways to assist the parents that play to their strengths. The Internet affords an extra teaching

tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices

can turn sound into light flashes to help pick up a child’s cry. Sign language is readily

acquired by young children.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 523

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

17. With regard to the adaptation of other family members, mainly siblings and

grandparents,to the newborn, nurses should be aware that:

Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and


a.
behaviors can take a long time to blow over.

b. Participation in preparation classes helps both siblings and grandparents.

In the United States paternal and maternal grandparents consider themselves of equal
c.
importance and status.

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In the past few decades the number of grandparents providing permanent care to their
d.
grandchildren has been declining.

ANS: B

Preparing older siblings and grandparents helps everyone to adapt. Sibling rivalry should be

expected initially, but the negative behaviors associated with it have been overemphasized

and stop in a comparatively short time. In the United States, in contrast to other cultures,

paternal grandparents frequently consider themselves secondary to maternal grandparents.

The number of grandparents providing permanent child care has been on the increase.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 525

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

18. Nursing activities that promote parent-infant attachment are many and varied. One

activitythat should not be overlooked is management of the environment. While providing

routine mother-baby care, the nurse should ensure that:

a. The baby is able to return to the nursery at night so that the new mother can sleep.

b. Routine times for care are established to reassure the parents.

The father should be encouraged to go home at night to prepare for mother-baby


c.
discharge.

d. An environment that fosters as much privacy as possible should be created.

ANS: D

Care providers need to knock before gaining entry. Nursing care activities should be grouped.

Once the baby has demonstrated adjustment to extrauterine life (either in the mother’s room

or the transitional nursery), all care should be provided in one location. This important

principle of family-centered maternity care fosters attachment by giving parents the

opportunity to learn about their infant 24 hours a day. One nurse should provide care to both

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mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to

return to the nursery at night. In fact, the mother will sleep better with the infant close by.

Care should be individualized to meet the parents’ needs, not the routines of the staff.

Teaching goals should be developed in collaboration with the parents. The father or other

significant other should be permitted to sleep in the room with the mother. The maternity unit

should develop policies that allow for the presence of significant others as much as the new

mother desires.
PTS: 1 DIF: Cognitive Level: Application REF: 528

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

19. The early postpartum period is a time of emotional and physical vulnerability. Many

mothers can easily become psychologically overwhelmed by the reality of their new

parentalresponsibilities. Fatigue compounds these issues. Although the baby blues are a

common occurrence in the postpartum period, about one-half million women in America

experience amore severe syndrome known as postpartum depression (PPD). Which

statement regarding PPD is essential for the nurse to be aware of when attempting to

formulate a nursing diagnosis?

a. PPD symptoms are consistently severe.

b. This syndrome affects only new mothers.

c. PPD can easily go undetected.

d. Only mental health professionals should teach new parents about this condition.

ANS: C

PPD can go undetected because parents do not voluntarily admit to this type of emotional

distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with

women having both good and bad days. Both mothers and fathers should be screened. PPD

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may also affect new fathers. The nurse should include information on PPD and how to

differentiate this from the baby blues for all clients on discharge. Nurses also can urge new

parents to report symptoms and seek follow-up care promptly if symptoms occur.
PTS: 1 DIF: Cognitive Level: Synthesis REF: 517

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

20. The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to:

a. The positive feedback an infant exhibits toward parents during the attachment process.

b. Behavior during the sensitive period when the infant is in the quiet alert stage.

c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact.

Behavior by the infant during the sensitive period to elicit feelings of “falling in love”
d.
from the parents.

ANS: A

In this definition, “reciprocal” refers to the feedback from the infant during the attachment

process. This is a good time for bonding; however, it does not define reciprocal attachment.

Reciprocal attachment applies to feedback behavior and is not unidirectional.


PTS: 1 DIF: Cognitive Level: Application REF: 518

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. The postpartum woman who continually repeats the story of her labor, delivery,

andrecovery experience is:

a. Providing others with her knowledge of events.

b. Making the birth experience “real.”

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c. Taking hold of the events leading to her labor and delivery.

d. Accepting her response to labor and delivery.

ANS: B

Reliving the birth experience makes the event real and helps the mother realize that the

pregnancy is over and that the infant is born and is now a separate individual. The retelling of

the story is to satisfy her needs, not the needs of others. This new mother is in the taking-in

phase, trying to make the birth experience seem real and separate the infant from herself.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 516

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

22. On observing a woman on her first postpartum day sitting in bed while her newborn

liesawake in the bassinet, the nurse should:

a. Realize that this situation is perfectly acceptable.

b. Offer to hand the baby to the woman.

c. Hand the baby to the woman.

d. Explain “taking in” to the woman.

ANS: C

During the “taking-in” phase of maternal adaptation (the mother may be passive and

dependent), the nurse should encourage bonding when the infant is in the quiet alert stage.

This is done best by simply giving the baby to the mother. The patient is exhibiting expected

behavior during the taking-in phase; however, interventions by the nurse can facilitate infant

bonding. The patient will learn best during the taking-hold phase.
PTS: 1 DIF: Cognitive Level: Application REF: 516

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OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

23. A nurse is observing a family. The mother is holding the baby she delivered less

than 24 hours ago. Her husband is watching his wife and asking questions about newborn

care. The4-year-old brother is punching his mother on the back. The nurse should:

a. Report the incident to the social services department.

b. Advise the parents that the toddler needs to be reprimanded.

c. Report to oncoming staff that the mother is probably not a good disciplinarian.

d. Realize that this is a normal family adjusting to family change.

ANS: D

The observed behaviors are normal variations of families adjusting to change. There is no

need to report this one incident. Giving advice at this point would make the parents feel

inadequate.
PTS: 1 DIF: Cognitive Level: Analysis REF: 518

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

24. The best way for the nurse to promote and support the maternal-infant bonding

process isto:

a. Help the mother identify her positive feelings toward the newborn.

b. Encourage the mother to provide all newborn care.

c. Assist the family with rooming-in.

d. Return the newborn to the nursery during sleep periods.

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ANS: C

Close and frequent interaction between mother and infant, which is facilitated by rooming-in,

is important in the bonding process. This is often referred to as the mother-baby care or

couplet care. Having the mother express her feelings is important; however, it is not the best

way to promote bonding. The mother needs time to rest and recuperate; she should not be

expected to do all of the care. The patient needs to observe the infant during all stages so she

will be aware of what to anticipate when they go home.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 516

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

25. During which phase of maternal adjustment will the mother relinquish the baby of

herfantasies and accept the real baby?

a. Letting go c. Taking in

b. Taking hold d. Taking on

ANS: A

Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go

phase of maternal adjustment. During the taking-hold phase the mother assumes

responsibility for her own care and shifts her attention to the infant. In the taking-in phase the

mother is primarily focused on her own needs. There is no taking-on phase of maternal

adjustment.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 516

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. 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. Your

initialaction should be to

a. Assess her for pain.

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b. Point out how lucky she is to have a healthy baby.

c. Explain that she is experiencing postpartum blues.

d. Allow her time to express her feelings.

ANS: D

Although many women experience transient postpartum blues, they need assistance in

expressing their feelings. This condition affects 50% to 80% of new mothers. There should be

no assumption that the patient is in pain, when in fact she may have no pain whatsoever. This

is “blocking” communication and inappropriate in this situation. The patient needs the

opportunity to express her feelings first; patient teaching can occur later.
PTS: 1 DIF: Cognitive Level: Application REF: 517

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

27. A man calls the nurse’s station and states that his wife, who delivered 2 days ago, is

happyone minute and crying the next. The man says, “She was never like this before the

baby was born.” The nurse’s initial response could be to:

a. Tell him to ignore the mood swings, as they will go away.

b. Reassure him that this behavior is normal.

c. Advise him to get immediate psychological help for her.

d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: B

Before providing further instructions, inform family members of the fact that postpartum

blues are a normal process. Telling her partner to “ignore the mood swings” does not

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encourage further communication and may belittle the husband’s concerns. Postpartum blues

are usually short-lived; no medical intervention is needed. Client teaching is important;

however, the new father’s anxieties need to be allayed before he will be receptive to teaching.
PTS: 1 DIF: Cognitive Level: Application REF: 517

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

28. To promote bonding and attachment immediately after delivery, the most

importantnursing intervention is to:

a. Allow the mother quiet time with her infant.

b. Assist the mother in assuming an en face position with her newborn.

c. Teach the mother about the concepts of bonding and attachment.

d. Assist the mother in feeding her baby.

ANS: B

Assisting the mother in assuming an en face position with her newborn will support 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. This is a

good time to initiate breastfeeding; however, the mother first needs time to explore the new

infant and begin the bonding process.


PTS: 1 DIF: Cognitive Level: Application REF: 519

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

29. A new father states, “I know nothing about babies,” but he seems to be

interested inlearning. This is an ideal opportunity for the nurse to:

a. Continue to observe his interaction with the newborn.

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b. Tell him when he does something wrong.

c. Show no concern, as he will learn on his own.

d. Include him in teaching sessions.

ANS: D

The nurse must be sensitive to the father’s needs and include him whenever possible. As

fathers take on their new role, the nurse should praise every attempt, even if his early care is

awkward. It is important to note the bonding process of the mother and the father; however,

that does not satisfy the expressed needs of the father. The new father should be encouraged

in caring for his baby by pointing out the things that he does right. Criticizing him will

discourage him.
PTS: 1 DIF: Cognitive Level: Application REF: 521

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

30. Which concerns about parenthood are often expressed by visually impaired mothers

(Select all that apply)?

a. Infant safety

b. Transportation

c. The ability to care for the infant

d. Missing out visually

e. Needing extra time for parenting activities to accommodate the visual limitations

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ANS: A, B, D, E

Concerns expressed by visually impaired mothers include infant safety, extra time needed for

parenting activities, transportation, handling other people’s reactions, providing proper

discipline, and missing out visually. Blind people sense reluctance on the part of others to

acknowledge that they have a right to be parents; however, blind parents are fully capable of

caring for their infants.


PTS: 1 DIF: Cognitive Level: Comprehension REF: 524

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

31. A parent who has a hearing impairment is presented with a number of challenges in

parenting. Which nursing approaches are appropriate for working with hearing-impaired

newparents (Select all that apply)?

a. Use devices that transform sound into light.

b. Assume that the patient knows sign language.

c. Speak quickly and loudly.

d. Ascertain whether the patient can read lips before teaching.

e. Written messages aid in communication.

ANS: A, D, E

Section 504 of the Rehabilitation Act of 1973 requires that hospitals use various

communication techniques and resources with the deaf and hard of hearing patient. This

includes devices such as door alarms, cry alarms, and amplifiers. Before initiating

communication, the nurse needs to be aware of the parents’ preferences for communication.

Not all hearing-impaired patients know sign language. Do they wear a hearing aid? Do they

read lips? Do they wish to have a sign language interpreter? If the parent relies on lip reading,

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TOPMARKSOLUTIONS

the nurse should sit close enough so that the parent can visualize lip movements. The nurse

should speak clearly in a regular voice volume, in short, simple sentences. Written messages

such as on a black or white erasable board can be useful. Written materials should be

reviewed with the parents before discharge.


PTS: 1 DIF: Cognitive Level: Application REF: 524

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

2023

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