Chapter 18: Postpartum Psychosocial Adaptations

Match each term with the correct definition of maternal adaptation stages . a. Passive, dependent b. Begins to see self as a mother c. Autonomous, seeking information 27. Taking-in 28. Letting-go 29. Taking-hold

27. ANS: A 28. ANS: B 29. ANS: C PTS: 1 DIF: Cognitive Level: Remember REF: 353 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: The progression of adaptation through the maternal stages includes taking-in (passive, dependent), taking-hold (autonomous, seeking information), and letting-go (begins to see self as a mother).

3. During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Formal b. Informal c. Personal d. Anticipatory

ANS: A A major task of the formal stage of role attainment is getting acquainted with the infant. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes. PTS: 1 DIF: Cognitive Level: Understanding REF: 354 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrit

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

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

13. Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources b. Recommends employing babysitters frequently c. Tells the parents about the realities of parenthood d. Offers a home phone number and tells parents to call if they have a question

ANS: A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task. However, the nurse should not give her personal number to clients. PTS: 1 DIF: Cognitive Level: Application REF: 354 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.

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

4. The nurse observes a client on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which appropriate action should the nurse take? a. Hand the baby to the woman. b. Explain "taking-in" to the woman. c. Offer to hand the baby to the woman. d. No action, because this situation is perfectly acceptable.

ANS: A During the taking-in phase of maternal adaptation, in which 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. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase. However, interventions can facilitate infant bonding. PTS: 1 DIF: Cognitive Level: Application REF: 353 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity

17. The postpartum nurse is reviewing dietary practices for an Asian client. Which should the nurse expect to observe as a dietary practice for this culture? a. Food brought from home b. Preference for fresh fruits c. Preference for "cold" foods d. Request for ice water instead of hot water

ANS: A Food brought from home is a welcome sign of caring in many cultures. Some Asians believe that after childbirth the woman should eat only "hot" foods such as chicken, meat, and fish. Fresh fruit would be considered a "cold" food. Although ice water is commonly given to hospital clients, it is not acceptable to many Asians. For example, Southeast Asian women may refuse cold or ice water and prefer hot water or other warm beverages to keep warm. PTS: 1 DIF: Cognitive Level: Application REF: 362 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. The postpartum client who continually repeats the story of her labor, birth, and recovery experiences is doing which? a. Making the birth experience "real" b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. Taking hold of the events leading to her labor and birth

ANS: A 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. She is in the taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not the needs of others. She is trying to make the event real and is trying to separate the infant from herself. PTS: 1 DIF: Cognitive Level: Understanding REF: 353 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

16. A new father states, "I know nothing about babies," but he seems to be interested in learning. The nurse should take which action? a. Include him in teaching sessions. b. Tell him when he does something wrong. c. Show no concern because he will learn on his own. d. Continue to observe his interaction with the newborn.

ANS: A The nurse must be sensitive to the father's needs and include him whenever possible. He should be encouraged by pointing out the correct procedures he does. By criticizing, he will be discouraged. Showing no concern is not a nursing role. Nurses need to be sensitive to clients' needs. It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father. PTS: 1 DIF: Cognitive Level: Application REF: 357 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

12. Which client is most likely to have the least stress adjusting to her role as a mother? a. A 26-year-old woman who is returning to work in 10 weeks b. A 35-year-old anxious mother who has had no contact with babies or children c. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

ANS: A The woman who has the least amount of stress in her life will adjust more quickly to her role as a mother. The anxious mother with no real experience with babies may have a difficult time adjusting to motherhood. The teenager has a significant amount of stress in her life, which could make adjusting to her role as a mother more difficult. The 25-year-old mother has the added stress of twins, which may make motherhood adjustment more difficult. PTS: 1 DIF: Cognitive Level: Understanding REF: 356 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

25. Which are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a. Provide comfort and ample time for rest. b. Keep the baby wrapped to avoid cold stress. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way. e. Limit the amount of modeling so the mother doesn't feel insecure.

ANS: A, C, D Provide comfort and ample time for rest, because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. Position the infant in an en face position and discuss the infant's ability to see the parent's face. Face to face and eye to eye contact is a first step in establishing mutual interaction between the infant and parent. Point out the characteristics of the infant in a positive way: "She has such pretty little hands and beautiful eyes." The baby should be kept warm, but parents should be assisted to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the toes, fingers, and body. The nurse should model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones. PTS: 1 DIF: Cognitive Level: Application REF: 364 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

26. Which strategies should the nurse suggest to a postpartum client to promote stress reduction during the first weeks at home? (Select all that apply.) a. Limiting coffee, tea, cola, and any caffeinated beverages b. Maintaining a rigid schedule c. Sleeping when the infant sleeps d. Inviting visitors and friends to stop by frequently e. Using learned breathing techniques from childbirth classes for relaxation

ANS: A, C, E To promote stress reduction during the first weeks at home, the nurse can suggest that parents limit coffee, tea, colas, and chocolate, because they contain caffeine and will interfere with rest. Recommend that the mother sleep when the infant sleeps and conserve her energy for care of the baby. Suggest breathing exercises and progressive relaxation to reduce stress and increase her energy level, especially when a nap is not possible. The schedule should be flexible; a rigid schedule or meticulous environment increases tension within the family. The parents should let friends and relatives know sleep and nap times and request that they limit visits or telephone before visiting. PTS: 1 DIF: Cognitive Level: Application REF: 366 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

19. An example of binding in during the postpartum period is a: a. new mother telling her friends all about her labor and birth experience. b. father looking at his newborn and stating that he "looks like I did when I was a baby." c. mother reporting increasing anxiety during the postpartum period because she feels like she is all alone. d. mother wanting some time alone so that she can catch up on needed sleep.

ANS: B A new mother telling her friends all about her labor and birth experience is an example of binding in or claiming. A new mother telling her friends all about her labor and birth experience is an example of the taking-in phase of maternal adaptation. A mother who reports increasing anxiety during the postpartum period because she feels like she is all alone may be problematic and indicates that the client is experiencing significant stressors during the postpartum period. A mother wanting some time alone so that she can catch up on needed sleep is a normal reaction to the demands of the newborn and reflects that the client may need additional support during this time. PTS: 1 DIF: Cognitive Level: Analysis REF: 352 OBJ: Nursing Process Step: Evaluation 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.

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

1. The term reciprocal attachment behavior refers to which of the following? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback an infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

ANS: B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding but does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional. PTS: 1 DIF: Cognitive Level: Understanding REF: 352 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. The nurse is developing a plan of care for the patient's fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? a. Encourage the patient to call the baby by his or her first name. b. Stimulate the grasp reflex by placing the patient's finger in the infant's palm. c. Ask the patient if she wants her baby placed on her chest immediately after birth. d. Assess for familial characteristics and remark on the resemblance to the patient or the father.

ANS: C Bonding refers to the rapid initial attraction felt by parents for their infant. It is unidirectional, from parent to child, and is enhanced when parents and infants are permitted to touch and interact during the first 30 to 60 minutes after birth. During this time, the infant is in a quiet, alert state and seems to gaze directly at the parents. Infants are often placed skin to skin on the mother's chest or abdomen for bonding time immediately after birth. Nurses frequently delay procedures such as measurements and medication administration that would interfere with this time, so that parents can focus on their newborn baby. Attachment follows a progressive or developmental course that changes over time. It is rarely instantaneous. Unlike bonding, attachment is reciprocal—it occurs in both directions between parent and infant. PTS: 1 DIF: Cognitive Level: Application REF: 351 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

21. Which of the following behaviors would be applicable to a nursing diagnosis of risk for impaired parenting? a. En face behavior is observed between father and infant. b. Mother relates that she feels exhilarated postbirth. c. Mother states that she feels excessive fatigue as a result of the childbirth experience. d. Father displays finger tipping behavior toward infant.

ANS: C Fatigue can contribute to altered parenting because it may affect the level of interaction between parent and child. En face behavior acknowledges maternal-paternal attachment. A feeling of exhilaration is normal following a changing life cycle event such as childbirth. Finger tipping behavior conveys a sense of identification or claiming behavior. PTS: 1 DIF: Cognitive Level: Application REF: 362 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

18. The nurse is teaching new parents about behavior cues that indicate their infant has had enough stimulation. Which cues should the nurse include in the teaching session? a. The infant kicks his legs. b. The infant is quiet and alert. c. The infant splays his fingers. d. The infant looks at their faces.

ANS: C Nurses should help parents recognize signals that indicate when their infant has had enough interaction and wants to avoid further stimulation. These avoidance cues, such as looking away, splaying the fingers, arching the back, and fussiness, indicate that the infant needs a quiet time. Kicking legs, being quiet and alert, and looking at faces are not clues the infant is overstimulated. PTS: 1 DIF: Cognitive Level: Application REF: 366 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

14. Which action should the nurse do to provide support and encouragement to the new postpartum client? a. Recount how she solved her own problems. b. Correct the new mother at every opportunity. c. Praise the mother's early attempts at infant care. d. Explain to the new mother that everything will be fine.

ANS: C Positive reinforcement of the mother's attempt to provide care to the newborn will promote a healthy self-concept. The mother needs to learn how to solve problems on her own. Each person may use different techniques that work for that person. Correcting her actions would be discouraging to a new mother. She needs encouragement. Saying everything will be fine is blocking communication and further teaching. PTS: 1 DIF: Cognitive Level: Application REF: 360 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.

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

22. A family is concerned about how their 2-year-old son is going to react to the new baby. What intervention would help facilitate sibling attachment? a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role. d. Observe the son's reaction to the baby and let him decide when he wants to be introduced to his new sibling.

ANS: C Providing the older son with a special role designation and involving him in the care of the baby will facilitate sibling attachment. Spending individual time with the older child is recommended but will not facilitate sibling attachment. Although the older child should be supervised because of his age in terms of infant safety, this level of overprotection may inhibit sibling attachment. Observation of his behavior may be warranted, but the age of the child (2 years) does not warrant this type of control. PTS: 1 DIF: Cognitive Level: Analysis REF: 366 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity

5. A postpartum nurse is observing a client 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 big brother is punching his mother on the back. Which action should the nurse should take? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

ANS: C 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 as parents. This is normal for an adjusting family. PTS: 1 DIF: Cognitive Level: Analysis REF: 366 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

20. A postpartum client who is a gravida 4, para 4, comes to the office for her 6-week postpartum checkup. Her presentation is untidy and unkempt. The client states that she is not sleeping well and relates that she feels overwhelmed at times. According to the client, family members' responses have been nonsupportive. What recommendations would you advise to help the client at this time? a. Tell the client that this is a normal reaction to an increase in family size and that listening to music can help relieve anxiety. b. Tell the client to increase her exercise pattern because that will promote a sense of well-being. c. Make appropriate referrals for psychological intervention counseling because the client is exhibiting high-risk symptoms. d. Record the client's vital signs as part of the ongoing assessment and offer relaxation strategies as a method of support.

ANS: C This client is exhibiting symptoms that are consistent with postpartum depression, so she should be given priority intervention to maintain client safety. PTS: 1 DIF: Cognitive Level: Application REF: 355 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychological Integrity

15. Which should the nurse do to provide support to a new client who must return to full-time employment 6 weeks after a vaginal birth? a. Discuss child care arrangements with her. b. Allow her to solve the problem on her own. c. Reassure her that she'll get used to leaving her baby. d. Allow her to express her positive and negative feelings freely.

ANS: D Allowing the client to express feelings will provide positive support in her process of maternal adjustment. Discussing child care arrangements is an important step in anticipatory guidance but is not the best way to offer support. She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision. Reassuring her that she will get used to leaving the baby blocks communication and belittles the client's feelings. PTS: 1 DIF: Cognitive Level: Application REF: 356 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.

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

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.

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

24. A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's best response? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"

ANS: D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response "Sounds like postpartum depression" does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression. PTS: 1 DIF: Cognitive Level: Analysis REF: 355 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance