A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?

Correct Answer: D

Rationale: The correct answer is D because during the taking-hold phase, the client is focused on learning and mastering new skills related to caring for the newborn. Demonstrating how to perform a newborn bath aligns with this phase as it helps the client gain confidence and competence in newborn care. Discussing contraceptive options (choice A) is more appropriate during the let-go phase. Repeating information (choice B) may be necessary but is not the priority during the taking-hold phase. Listening to the client and her partner reflect on the birth experience (choice C) is important for emotional support but not specifically related to the behavioral adjustments in the taking-hold phase.

Correct Answer: A

Rationale: The correct answer is A. Late decelerations indicate fetal distress, suggesting compromised oxygenation. Starting oxytocin can further stress the fetus, worsening decelerations. Report to prevent harm. B is incorrect as moderate variability is a reassuring sign of fetal well-being. C is incorrect as cessation of uterine dilation may indicate uterine hyperstimulation, not fetal distress. D is incorrect as prolonged active labor phase alone doesn't necessarily contraindicate oxytocin, but it may require monitoring.

Correct Answer: C

Rationale: The correct answer is C: Weight gain of 2.2 kg (4.8 lb). This finding should be reported to the provider because sudden excessive weight gain in late pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This could indicate a potential complication that needs immediate medical attention. Explanation: A: Blood pressure 136/88 mm Hg - This blood pressure reading is slightly elevated but not concerning for preeclampsia at this level. B: Report of insomnia - Insomnia is a common issue during pregnancy and not typically a cause for immediate concern. D: Report of Braxton-Hicks contractions - Braxton-Hicks contractions are common in the third trimester and are considered normal as long as they are not regular or increasing in intensity.

Correct Answer: D

Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention. A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect. B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect. D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.