The nurse notes that a client who has given birth 1 hour ago is ...

[Mr. Wonderful]

The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?
 
  a. Request a social service consult for psychosocial support.
  b. Observe for other signs that the mother may not be accepting of the infant.
  c. Document this evidence of normal early maternal-infant attachment behavior.
  d. Determine whether the mother is too fatigued to interact normally with her infant.

Question 2

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?
 
  a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process
  b. Fatigue related to length of labor requiring increased energy expenditure
  c. Acute pain related to increased intensity of contractions
  d. Anxiety related to imminent birth process

[Smiles0805]

Answer to Question 1

ANS: C
Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

Answer to Question 2

ANS: D
A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

[Mr. Wonderful]

Correct answers!

[Smiles0805]

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