Chapter 22: Transition to Parenthood

22. 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 hold c. Taking in 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. A taking-on phase of maternal adjustment does not exist. DIF: Cognitive Level: Understand REF: p. 508

5. New parents express concern that because of the mothers emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. Which information should the nurses response convey? a. Attachment, or bonding, is a process that occurs over time and does not require early contact. b. Time immediately after birth is a critical period for humans. c. Early contact is essential for optimal parent-infant relationships. d. These new parents should just be happy that the infant is healthy.

ANS: A Attachment occurs over time and does not require early contact. Although a delay in contact does not necessarily mean that attachment is inhibited, additional psychologic energy may be necessary to achieve the same effect. The formerly accepted definition of bonding held that the period immediately after birth was critical 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. Telling the parents that they should be happy that the infant is healthy is inappropriate; it may be received as derogatory and belittling. DIF: Cognitive Level: Apply REF: p. 505

7. Which statement by the nurse can assist a new father in his transition to parenthood? 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 infants 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, but 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.

17. When the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, what is the correct term for this behavior? a. Mutuality b. Bonding c. Claiming d. Acquaintance

ANS: A Mutuality extends the concept of attachment and includes a shared set of behaviors as part of the bonding process. Bonding is the process during which parents form an emotional attachment to their infant over time.Claiming is the process during which parents identify their new baby in terms of the infants likeness to other family members and their differences and uniqueness. Similar to 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. DIF: Cognitive Level: Remember REF: p. 502 TOP: Nursing Process: Evaluation

8. A nurse notes that an Eskimo 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. While evaluating this clients behavior with her infant, what realization does the nurse make? a. What appears to be a lack of interest in the newborn is, in fact, the cultural way of demonstrating intense love by attempting to ward off evil spirits. b. The woman is inexperienced in caring for a newborn. c. The woman needs a referral to a social worker for further evaluation of her parenting 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 an Eskimo mother 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 groups attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. Inexperience in caring for newborns is not an issue. Cultural beliefs are important determinates of parenting behaviors. The womans lack of interest is an Eskimo cultural behavior. Referring the woman to a social worker is not necessary in this situation. The lack of infant interaction is not a form of infant neglect; rather, it is a demonstration of love and concern for the infant. The nurse may observe the woman and may be concerned by the apparent lack of interest in the newborn when in fact her behavior is a cultural display of love and concern for the infant. Teaching the woman infant care is important, but acknowledging her cultural beliefs and practices is equally important. DIF: Cognitive Level: Understand REF: p. 516 TOP: Nursing Process: Evaluation

3. Which societal factors have a strong influence on parental response to their infant? (Select all that apply.) a. An adolescent mothers egocentricity and unmet developmental needs interfere with her ability to parent effectively. b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers. c. Adolescent mothers have a higher documented incidence of child abuse. d. Mothers older than 35 years of age often deal with more stress related to work and career issues, as well as decreasing libido. e. Relationships between adolescent mothers and fathers are more stable than older adults.

ANS: A, B, D Adolescent mothers are more inclined to have a number of parenting difficulties that can benefit from counseling, but a higher incidence of child abuse is not one of them. As adolescent mothers move through the transition to parenthood, they can feel different from their peers, excluded from fun activities, and prematurely forced to enter the adult role. The conflict between their own desires and the infants demands further contribute to the normal psychosocial stress of childbirth and parenting. Adolescent mothers provide warm and attentive physical care; however, they use less verbal interaction than older parents, and adolescents tend to be less responsive and to interact less positively with their infants than older mothers. Midlife mothers have many competencies; however, they are more likely to have to deal with career and sexual issues than are younger mothers. Relationships between adolescent parents tend to be less stable than among adults. DIF: Cognitive Level: Understand REF: pp. 513, 514 TOP: Nursing Process: Evaluation

1. Which concerns regarding parenthood are often expressed by visually impaired mothers? (Select all that apply.) a. Infant safety b. Transportation c. Ability to care for the infant d. Visually missing out e. Needing extra time for parenting activities to accommodate the visual limitations

ANS: A, B, D, E Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other peoples reactions, providing proper discipline, and missing out visually. Blind people sense a 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. DIF: Cognitive Level: Understand REF: p. 517 TOP: Nursing Process: Evaluation

4. The transition to parenting for same-sex couples can present unique challenges. How can the nurse foster adjustment to parenting for these clients? (Select all that apply.) a. Use a supplemental feeding device to simulate breastfeeding. b. Allow the partner to cut the cord. c. Gay fathers should meet their new infant soon after the birth mother has recovered. d. Understand that strong social sanctions remain. e. Provide information regarding support groups.

ANS: A, B, D, E In a lesbian couple, the nonchildbearing partner may have a desire to breastfeed. This can be achieved using a supplemental nursing device. The female partner should be offered the same right as a heterosexual partner including cutting the cord. A gay couple may adopt a baby or use a surrogate. If the latter method is chosen, then they should be present at the birth if at all possible. The nurse can refer these men to available support groups. Same-sex couples continue to face strong social sanction in their efforts to parent. DIF: Cognitive Level: Apply REF: p. 515

5. 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 new parents? (Select all that apply.) a. Using devices that transform sound into light b. Assuming that the client knows sign language c. Speaking quickly and loudly d. Ascertaining whether the client can read lips before teaching e. Writing messages that 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 client. These resources include 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 clients 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, then the nurse should sit close enough to enable the parent to 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. DIF: Cognitive Level: Apply REF: pp. 517, 518 TOP: Nursing Process: Planning

15. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment after childbirth. Recognizing the needs of women during this stage, how should the nurse respond? a. Foster an active role in the babys care. b. Provide time for the mother to reflect on the events of her labor and delivery. c. Recognize the womans limited attention span by giving her written materials to read when she gets home rather than doing a teaching session while she is in the hospital. d. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

ANS: B During this stage, the new mother is excited and talkative. It is important that she be able to fulfill her desire to review her birth experience. During this stage, the new mother still relies upon others to meet her physical needs. Once these are met, she will be more able to take an active role, not only in her own care but also in the care of her newborn, which happens during the taking-hold stage. Short teaching sessions, using written materials to reinforce the content presented, is a more effective approach. The focus of the taking-in or dependency stage is to nurture the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. DIF: Cognitive Level: Apply REF: p. 508

18. In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which is a facilitating behavior? a. Parents have difficulty naming the infant. b. Parents hover around the infant, directing attention to and pointing at the infant. c. Parents make no effort to interpret the actions or needs of the infant. d. 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.

11. In addition to eye contact, other early sensual contacts between the infant and mother involve sound and smell. What other statement regarding the senses is correct? a. High-pitched voices irritate newborns. b. Infants can learn to distinguish their mothers voice from others soon after birth. c. All babies in the hospital smell alike. d. Mothers breast milk has no distinctive odor.

ANS: B Infants know the sound of their mothers voice at an early age. Infants positively respond to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mothers breast milk. DIF: Cognitive Level: Remember REF: p. 506 TOP: Nursing Process: Planning

3. The nurse observes that a first-time mother appears to ignore her newborn. Which strategy should the nurse use to facilitate mother-infant attachment? a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and attends 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 perceived as derogatory and is not appropriate. Educating the young mother in infant care is important, but 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 infants responsiveness is more appropriate. DIF: Cognitive Level: Apply REF: p. 502

13. The postpartum nurse should be cognizant of what with regard to the adaptation of other family members (primarily siblings and grandparents) to the newborn? a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over. b. Participation in preparation classes helps both siblings and grandparents. c. In the United States, paternal and maternal grandparents consider themselves of equal importance and status. d. Since 1990, the number of grandparents providing permanent care to their grandchildren has been declining.

ANS: B Preparing older siblings, as well as grandparents, helps with everyones adaptation. Sibling rivalry should be initially expected, 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 rising. DIF: Cognitive Level: Understand REF: pp. 517, 519 TOP: Nursing Process: Planning

20. The postpartum woman continually repeats the story of her labor, delivery, and recovery experience. What is this new mother attempting to achieve with this behavior? a. Providing others with her knowledge of events b. Making the birth experience real c. Taking hold of the events leading up 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 satisfies 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. DIF: Cognitive Level: Understand REF: p. 508

9. Many first-time parents do not plan on having their parents help immediately after the newborn arrives. Which statement by the nurse is the most appropriate when counseling new parents regarding the involvement of grandparents? a. You should tell your parents to leave you alone. b. Grandparents can help you with parenting skills. 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 Telling the parents that grandparents can help with parenting skills and therefore help preserve family traditions is the most appropriate response. Intergenerational help may be perceived as interference, but telling the parents that their parents should be told to leave them alone is not therapeutic to the adaptation of the family. Telling the parents that grandparent involvement can be disruptive to the family is an invalid statement and not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. DIF: Cognitive Level: Analyze REF: p. 518 TOP: Nursing Process: Planning

16. 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? a. The postpartum woman talks and coos to her son. b. She seldom makes eye contact with her son. c. The mother cuddles her son close to her. d. She tells visitors how well her son is feeding.

ANS: B The mother 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. DIF: Cognitive Level: Apply REF: p. 503 TOP: Nursing Process: Assessment | Nursing Process: Diagnosis

2. In the United States, the en face position is preferred immediately after birth. Which actions by the nurse can facilitate this process? (Select all that apply.) a. Washing both the infants face and the mothers face b. Placing the infant on the mothers abdomen or breast with their heads on the same plane c. Dimming the lights d. Delaying the instillation of prophylactic antibiotic ointment in the infants eyes e. Placing the infant in the grandmothers arms

ANS: B, C, D As newborns become functionally able to sustain eye contact with their parents, they spend time in mutual gazing, often in the en face position, a position in which the faces of the parent and infant are approximately 20 cm apart and on the same plane. Washing the faces of the infant or mother is not necessary at this time and would interrupt the process. Nurses and physicians or midwives can facilitate eye contact immediately after birth by placing the infant on the mothers abdomen or breasts with the mother and the infants faces on the same plane. Dimming the lights encourages the infants eyes to stay open. To promote eye contact, the instillation of prophylactic antibiotic ointment into the infants eyes can be delayed until after the infant and parents have had some time together during the first hour after birth. Having the grandmother hold the infant is important; however, it will not necessarily promote eye contact between the parent and infant. DIF: Cognitive Level: Apply REF: p. 506

4. A nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dads. This statement is most descriptive of which process? a. Mutuality b. Synchrony c. Claiming 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 infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the fit between the infants cues and the parents responses. Reciprocity is a type of body movement or behavior that provides the observer with cues. DIF: Cognitive Level: Understand REF: pp. 502, 504 TOP: Nursing Process: Evaluation

6. During a telephone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, I dont know whats wrong. I love my son, but I feel so let down. I seem to cry for no reason! Which condition might this new mother be experiencing? a. Letting-go b. Postpartum depression (PPD) c. Postpartum blues d. Attachment difficulty

ANS: C During the postpartum blues, women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth postpartum day. The letting-go phase is the period that occurs several weeks after childbirth. During this phase the woman wants to move forward as a family unit with all members, appropriately interacting to their new roles. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the postpartum blues. Crying is not a maladaptive attachment response; it indicates postpartum blues. DIF: Cognitive Level: Understand REF: p. 509

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 parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, approximately 500,000 women in America experience a more severe syndrome known as 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. PPD may also affect new fathers. Therefore, both mothers and fathers should be screened. The nurse should include information on PPD and how to differentiate it from the baby blues for all clients before discharge. Nurses can also urge new parents to report symptoms and to seek follow-up care promptly if symptoms occur.

23. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. The nurses next action should be what? a. Assess her for pain. 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. Postpartum blues affects 50% to 80% of new mothers. An assumption that the client is in pain should not be made when, in fact, she may have no pain whatsoever. Making this assumption would be blocking communication and inappropriate in this situation. The client needs the opportunity to express her feelings first; client teaching can occur later. DIF: Cognitive Level: Apply REF: p. 509

14. While providing routine mother-baby care, which activities should the nurse encourage to facilitate the parent-infant attachment? 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. c. The father should be encouraged to go home at night to prepare for discharge of the mother and baby. 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 an adjustment to extrauterine life (either in the mothers room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by offering parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both 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 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.

10. In follow-up appointments or visits with parents and their new baby, it is useful if the nurse can identify infant behaviors that can either facilitate or inhibit attachment. What is an inhibiting behavior? a. The infant cries only when hungry or wet. b. The infants activity is somewhat predictable. c. The infant clings to the parents. d. The infant seeks attention from any adult in the room.

ANS: D Parents want to be the focus of the infants existence, just as the infant is the focus of their existence. Facilitating and inhibiting behaviors build or discourage bonding (attitudes); they do not reflect any value judgments on what might be healthy or unhealthy. The infant who shows no preference for his or her parents over other adults is exhibiting an inhibiting behavior. An infant who cries only when hungry or wet is exhibiting a facilitating behavior. An infant who has a predictable attention span is exhibiting a facilitating behavior. The infant who clings to his or her parents, enjoys being cuddled and held, and is easily consoled is displaying facilitating behaviors.

12. After birth, a crying infant may be soothed by being held in a position in which the newborn can hear the mothers heartbeat. This phenomenon is known as what? a. Entrainment b. Reciprocity c. Synchrony 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 a newborn in time to the structure of adult speech. Reciprocity is body movement or behavior that gives cues to the persons desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infants behavioral cues and the parents responses. DIF: Cognitive Level: Remember REF: p. 507

24. A new father states, I know nothing about babies; however, he seems to be interested in learning. How would the nurse best respond to this father? a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern; he will learn on his own. d. Include him in teaching sessions.

ANS: D The nurse must be sensitive to the fathers 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. Although noting the bonding process of the mother and the father is important, it does not satisfy the expressed needs of the father. The new father should be encouraged to care for his baby by pointing out the things that he does right. Criticizing him will discourage him. DIF: Cognitive Level: Apply REF: p. 511 TOP: Nursing Process: Planning

21. 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. The 4-year-old brother is punching his mother on the back. How should the nurse react to this situation? 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 unit adjusting to a major family change.

ANS: D The observed behaviors are normal variations of a family adjusting to change. Reporting this one incident is not needed. Offering advice at this point would make the parents feel inadequate. DIF: Cognitive Level: Analyze REF: pp. 517-518

2. A 30-year-old multiparous woman has a boy who is years old and has recently delivered an infant girl. She tells the nurse, I dont know how Ill ever manage both children when I get home. Which suggestion would assist this new mother in alleviating sibling rivalry? a. Tell the older child that he is a big boy now and should love his new sister. b. Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn. c. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. d. Realize that the regression in habits and behaviors in the older child is a typical reaction and that he needs extra love and attention at this time.

ANS: D The older child may regress in habits or behaviors (e.g., toileting, sleep habits) as a method of seeking attention. Parents need to distribute their attention in an equitable manner. Telling the older child that he should love his new sister is a negative approach to facilitating sibling acceptance of the new infant. Reactions of siblings may result from temporary separation from the mother. Removing the older child from the home when the new infant arrives may enhance negative behaviors from the older child caused by a separation from the mother. Providing small gifts from the infant to the older child is a strategy for facilitating sibling acceptance of the new infant. DIF: Cognitive Level: Analyze REF: p. 517 TOP: Nursing Process: Planning

1. After giving birth to a healthy infant boy, a primiparous client, 16 years of age, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Deficient knowledge of infant care. What should the nurse be certain to include in the plan of care as he or she prepares the client for discharge?

a. Teach the client how to feed and bathe her infant. b. Give the client written information on bathing her infant. c. Advise the client that all mothers instinctively know how to care for their infants. d. Provide time for the client to bathe her infant after she views a demonstration of infant bathing. ANS: D Having the mother demonstrate infant care is a valuable method of assessing the clients 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 client education or providing written information might be useful, neither is the most developmentally appropriate teaching method for a teenage mother. Advising the young woman that all mothers instinctively know how to care for their infants is inappropriate; it is belittling and false.