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?
Eagerness to learn newborn care skills
Lack of appetite
Expressions of excitement
Focus on the family unit and its members
The Correct Answer is C
Choice A reason: During the taking-in phase, the mother is often passive and may not yet show eagerness to learn newborn care skills. This phase is more about recovery and processing the birth experience.
Choice B reason: Lack of appetite might be present immediately after birth due to the exertion and possible nausea, but it is not a defining characteristic of the taking-in phase. The mother's appetite usually returns as she begins to recover.
Choice C reason: Expressions of excitement are common as the mother relives the delivery experience and begins to bond with the baby. This emotional response is part of the taking-in phase, where the mother is focused on her own experience and the reality of becoming a parent.
Choice D reason: While the focus on the family unit is important, during the taking-in phase, the mother is primarily oriented to her own needs and recovery. The focus on family members and the broader family unit becomes more prominent in the subsequent taking-hold phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
An irregular fetal heart rate is not typically associated with a hydatidiform mole because, in many cases of complete molar pregnancy, there is no fetus, and thus no fetal heart rate to assess. In partial molar pregnancies, there may be a fetus with an irregular heart rate, but this is not a definitive sign of a hydatidiform mole.
Choice b reason:
Profuse, clear vaginal discharge is not a common finding in hydatidiform mole. The typical vaginal discharge associated with a molar pregnancy is often described as "grape-like" or "prune juice-like" due to the presence of molar tissue being passed.
Choice c reason:
A rapid decline in hCG levels is not expected in hydatidiform mole; in fact, unusually high levels of hCG are more characteristic of this condition. The abnormal placental tissue in a molar pregnancy tends to produce higher than normal amounts of hCG.
Choice d reason:
Excessive uterine enlargement is a key finding in hydatidiform mole. The uterus often becomes larger than expected for the gestational age because the abnormal placental tissue grows rapidly and takes up more space within the uterus. This can happen within 10 to 16 weeks of gestation and is one of the primary clinical signs that lead to the suspicion of a molar pregnancy.
Correct Answer is A
Explanation
Choice a reason:
Elevated blood pressure is a primary indicator for preeclampsia, which is a condition characterized by hypertension and often proteinuria after 20 weeks of gestation. The criteria for hypertension in pregnancy are a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least 4 hours apart. If a pregnant client presents with elevated blood pressure, it is crucial for the nurse to initiate further evaluation for preeclampsia, as this condition can lead to serious complications for both the mother and the fetus.
Choice b reason:
Joint pain is not a typical sign of preeclampsia. While joint pain can be a symptom experienced during pregnancy due to various physiological changes, it is not specifically associated with preeclampsia and does not warrant further evaluation for this disorder on its own.
Choice c reason:
Vaginal discharge during pregnancy is common and can vary in consistency and amount. It is not a specific indicator of preeclampsia unless accompanied by other symptoms such as elevated blood pressure or proteinuria. Normal vaginal discharge is usually clear or milky white and does not indicate the need for preeclampsia evaluation.
Choice d reason:
Increased urine output is not typically associated with preeclampsia. In fact, preeclampsia can sometimes lead to reduced urine output due to kidney impairment. If a client has increased urine output, it may be due to other factors such as increased fluid intake or gestational diabetes.
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