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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Correct Answer is C
Explanation
Choice a reason:
Placing the client in the Trendelenburg position, which involves lying on the back with the feet higher than the head, is not indicated for the symptoms presented. This position is typically used to treat hypotension or improve venous return to the heart, not for respiratory depression or absent deep-tendon reflexes, which are signs of magnesium sulfate toxicity.
Choice b reason:
Assessing maternal blood glucose is important in the overall care of a preeclamptic patient, especially if there is a concern for gestational diabetes. However, it is not the immediate action required when a patient exhibits signs of magnesium sulfate toxicity, such as a respiratory rate of 10/min and absent deep-tendon reflexes.
Choice c reason:
Discontinuing the medication infusion is the correct action. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Immediate cessation of the drug is necessary to prevent further complications, such as respiratory depression or cardiac arrest. After stopping the infusion, the nurse should monitor the patient closely and prepare to administer calcium gluconate, the antidote for magnesium sulfate toxicity, if ordered by the physician.
Choice d reason:
Preparing for an emergency cesarean birth may be necessary if the fetus is in distress or if there are other obstetric indications. However, the information provided does not indicate fetal distress or an immediate need for delivery. The priority is addressing the signs of magnesium sulfate toxicity in the mother.
Correct Answer is B
Explanation
Choice A reason:
Type 1 diabetes mellitus is generally not directly associated with maternal smoking. It is an autoimmune condition where the pancreas produces little to no insulin. Risk factors for Type 1 diabetes include family history and possibly environmental factors, but maternal smoking is not a recognized risk factor.
Choice B reason:
Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes of IUGR are many, but maternal smoking is a well-documented risk factor. Smoking during pregnancy can reduce oxygen and nutrient delivery to the fetus, leading to low birth weight and other complications.
Choice C reason:
While smoking during pregnancy can increase the risk of various health issues, there is no direct and consistent evidence linking it to hearing loss in newborns. Hearing loss in newborns can be due to genetic factors, infections during pregnancy, or complications at birth.
Choice D reason:
Congenital heart defects are the most common type of birth defect, and their causes can be multifactorial, including genetic and environmental factors. Maternal smoking has been associated with an increased risk of certain congenital heart defects, but the relationship is not as strong as with intrauterine growth restriction.
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