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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.

Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.

Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.

Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.

A. "Exposure to rubella will suppress the newborn's immune response." B. "The child might develop encephalitis, a complication of rubella." C. "The newborn is at risk for developing a TORCH infection." D. "The newborn might be actively shedding the virus."

Correct Answer is D

Explanation

Choice A reason:
The statement that exposure to rubella will suppress the newborn's immune response is not entirely accurate. While rubella can affect the immune system, the primary concern with newborns is the risk of congenital rubella syndrome (CRS), which can cause a variety of health problems, including developmental delays and organ damage. The newborn's immune system is not fully developed, and while rubella can lead to immunosuppression, the main reason for isolation is to prevent the spread of the virus.

Choice B reason:
Encephalitis is an inflammation of the brain that can be caused by various infections, including rubella. However, it is not the most common complication associated with congenital rubella. The primary concerns with CRS are hearing loss, heart defects, and ocular issues, such as cataracts. While encephalitis is a serious condition, the immediate reason for isolation is to prevent the transmission of the virus, not specifically because of the risk of encephalitis.

Choice C reason:
TORCH infections refer to a group of infections that can cause serious health problems in newborns. The acronym stands for Toxoplasmosis, Other (such as syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. While it is true that the newborn is at risk for developing CRS, which is part of the TORCH group, the term "TORCH infection" is a broader category and does not specifically explain why the newborn is being isolated.

Choice D reason:
The most appropriate response is that the newborn might be actively shedding the virus. Newborns with congenital rubella can shed the virus for an extended period after birth. This means they can potentially spread the virus to others, which is why isolation is necessary. Isolation helps protect other newborns, pregnant women, and immunocompromised individuals from contracting rubella, which can have serious consequences.

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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?

Nursing Test Bank

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"How will I know if my baby is getting enough breast milk?"

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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