A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

Choice A Reason:
Iron is not poorly absorbed in infants; in fact, infants absorb iron quite efficiently. Breast milk contains a small amount of iron, but it is highly bioavailable and well-absorbed. When switching to formula, it is important to use iron-fortified options to prevent iron deficiency anemia.

Choice B Reason:
While iron is essential for overall growth and development, including bone growth, it is not the primary reason for emphasizing iron in infant nutrition. The key concern with iron, especially when transitioning from breastfeeding, is the prevention of iron deficiency anemia, which can affect cognitive and motor development.

Choice C Reason:
This is the correct information to include in the teaching. Infants are born with a reserve of iron that begins to deplete around 4 to 6 months of age. It is crucial to introduce iron-fortified formula at this time to ensure the infant continues to receive adequate iron for development and to prevent iron deficiency anemia.

Choice D Reason:
Iron does play a role in the development of the nervous system, which can indirectly affect vision, but it is not specifically known for facilitating the development of vision in infants. The primary concern with iron intake in infants relates to its role in preventing anemia and supporting overall growth and development.

Choice A reason:
Administering oxygen using a non-rebreather mask is a subsequent step if initial measures do not improve fetal heart rate decelerations. It can help increase the amount of oxygen available to the fetus. Oxygen administration is a supportive measure that can be used if there are signs of fetal distress. In the scenario described, where the fetal heart rate slows after the start of a contraction with the lowest rate occurring after the peak, it suggests late decelerations, which are often associated with uteroplacental insufficiency. Administering oxygen can help increase the fetal oxygen reserve and is a common intervention during labor when there are concerns about fetal well-being.

Choice B reason:
Increasing the rate of maintenance IV infusion is typically considered when there is a concern for maternal hypotension or dehydration, which may not be the immediate cause of the observed fetal heart rate pattern. Increasing the rate of an IV infusion can help improve maternal hydration and blood pressure, which in turn can enhance placental perfusion. However, this intervention is more indirect and may not provide the immediate response needed to address fetal heart rate decelerations. It is typically considered after more direct interventions, such as repositioning the mother, have been attempted.

Choice C reason:
Elevating the client's legs can help improve venous return to the heart, potentially increasing maternal cardiac output and blood flow to the placenta. While this can be beneficial, it is not the primary intervention for late decelerations. Repositioning the mother to improve uteroplacental circulation is generally the first step.
Choice D reason:
Placing the client in the lateral position is often the first action taken when late decelerations are observed. This position helps improve uteroplacental blood flow and can quickly address potential issues related to fetal oxygenation. This position helps to relieve pressure on the inferior vena cava and aorta, which can be compressed by the gravid uterus, especially in the supine position. Relieving this pressure helps to improve uteroplacental circulation and can quickly address the cause of late decelerations, which is often related to compromised blood flow to the placenta.