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:
Magnesium sulfate is used in the management of severe preeclampsia primarily for seizure prophylaxis. One of the key side effects of magnesium sulfate is its impact on neuromuscular transmission, leading to diminished deep-tendon reflexes as serum magnesium levels rise. The therapeutic range for anticonvulsant prophylaxis is typically between 5-8 mg/dL. Reflexes may begin to diminish when serum levels reach 8-12 mg/dL, indicating potential magnesium toxicity. Therefore, diminished reflexes are a warning sign to reassess the infusion rate and possibly reduce or discontinue the medication.

Choice B reason:
A respiratory rate of 16 breaths per minute falls within the normal adult range and suggests that the client's respiratory system is not being adversely affected by the magnesium sulfate infusion. Respiratory rate is a critical parameter to monitor during magnesium sulfate therapy, as respiratory depression is a serious side effect of magnesium toxicity. Maintaining a normal respiratory rate indicates that it is safe to continue the infusion at the current rate.

Choice C reason:
While a urine output of 50 mL/hr is on the lower end of the normal range, it is still considered adequate for most adults. In the setting of magnesium sulfate therapy for severe preeclampsia, maintaining adequate urine output is essential for ensuring that the kidneys can excrete the magnesium to prevent accumulation and toxicity. If urine output decreases significantly, it may necessitate reevaluation of the infusion rate or additional interventions to support renal function.

Choice D reason:
A heart rate of 56 beats per minute is slightly bradycardic but may not be clinically significant if the client is asymptomatic. However, magnesium has a direct effect on cardiac function, and high levels can lead to bradycardia and other cardiac conduction abnormalities. It is important to monitor the client's heart rate and rhythm during magnesium sulfate therapy to detect any early signs of cardiac involvement due to magnesium toxicity.

A. Suction excess mucus with a bulb syringe. B. Initiate early feeding. C. Prepare for an exchange blood transfusion. D. Begin phototherapy.

Correct Answer is B

Explanation

Choice A reason:
Suctioning excess mucus with a bulb syringe is a standard procedure to clear the airways of a newborn and facilitate breathing. While it is an important aspect of initial newborn care, it does not directly prevent jaundice. Jaundice is caused by high levels of bilirubin in the blood, and suctioning mucus does not influence bilirubin levels.

Choice B reason:
Initiating early feeding, whether breastfeeding or formula feeding, is recommended to prevent jaundice. Early feeding helps stimulate bowel movements, which aids in the excretion of bilirubin through the stool. Breastfed babies should be fed eight to twelve times a day during their first week of life, and formula-fed babies should receive one to two ounces (30 to 60 milliliters) of formula every two to three hours during their first week. This frequent feeding schedule helps ensure that bilirubin does not build up to high levels in the newborn's system.

Choice C reason:
Preparing for an exchange blood transfusion is a treatment measure for severe jaundice, not a preventive action. This procedure is only considered when bilirubin levels are dangerously high and could potentially cause brain damage. It is not a standard preventive measure for jaundice in newborns.

Choice D reason:
Beginning phototherapy is a treatment method for newborns who have already developed jaundice, not a preventive measure. Phototherapy uses light to break down bilirubin in the skin, making it easier for the baby's body to eliminate it. While effective in treating jaundice, it is not used as a preventive action.
Question 65

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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 is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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