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:

The left lower quadrant is not typically where fetal heart tones are auscultated when the round, firm part of the fetus (usually the head) is palpated in the fundus and the long smooth surface (indicative of the back) is on the right side. Fetal heart tones are best heard through the back of the fetus, and in this position, the back is not located in the left lower quadrant.

Choice B reason:

The right upper quadrant is the correct location to auscultate fetal heart tones in this scenario. The Leopold's maneuvers suggest that the fetus is in a cephalic presentation with its back facing the right side of the mother's abdomen. Therefore, the fetal heart tones are most likely to be heard in the right upper quadrant, just below the level of the fundus.

Choice C reason:

The right lower quadrant is generally not the area to auscultate fetal heart tones if the fetus's back is on the right side and the head is in the fundus. The heart tones are typically higher up and closer to where the back is palpated.

Choice D reason:

The left upper quadrant would not be the correct place to find fetal heart tones given the described position of the fetus. With the back on the right side, auscultation on the left would not yield the clear heart tones expected.

A. "You should not receive the rubella vaccine while breastfeeding." B. "You should receive a varicella vaccine before you deliver." C. "You cannot receive the Tdap vaccine until after you deliver." D. "You can receive an influenza vaccination during pregnancy."

Correct Answer is D

Explanation

Choice A reason: The rubella vaccine is a live attenuated virus vaccine, which is generally not recommended during pregnancy due to the theoretical risk to the fetus. However, it is safe to receive the rubella vaccine while breastfeeding; it does not pose a risk to the nursing infant.

Choice B reason: The varicella vaccine, which is also a live virus vaccine, should not be administered during pregnancy because of the potential risk to the fetus. Women should be vaccinated before pregnancy or in the postpartum period.

Choice C reason: The Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough), is recommended for all pregnant women during each pregnancy, regardless of their previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation to maximize the transfer of antibodies to the baby.

Choice D reason: Pregnant women are encouraged to receive the inactivated influenza vaccine at any point during their pregnancy. The flu shot is safe during pregnancy and helps protect both the mother and the baby from the flu and its complications.

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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

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client. Using Leopold's maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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