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 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.

A. "I will monitor my weight gain during the remaining months." B. "I will use only nonprescription medications while pregnant." C. "I will reduce my stress level." D. "I will tell my doctor before using home remedies for nausea."

Correct Answer is B

Explanation

Choice A reason:
Monitoring weight gain during pregnancy is important to ensure that the mother and baby are healthy. The expected weight gain during pregnancy varies depending on the mother's pre-pregnancy weight, but generally, a total gain of 25 to 35 pounds is considered normal for women of average weight.

Choice B reason:
While some nonprescription medications are safe during pregnancy, not all are, and it is crucial to consult with a healthcare provider before taking any medication, including over-the-counter ones. Certain medications can cause harm to the developing fetus and may lead to complications such as birth defects or other adverse outcomes.

Choice C reason:
Reducing stress is beneficial during pregnancy as high levels of stress can negatively impact both the mother and the developing fetus. Stress can lead to increased risks of preterm birth and low birth weight, and it can affect the baby's development. Therefore, implementing stress-reduction techniques is a positive step for a pregnant woman.

Choice D reason:
Informing the doctor before using home remedies for nausea is advisable. While many home remedies are safe and can be effective, such as ginger and peppermint, it is always best to discuss them with a healthcare provider to ensure they are appropriate and will not interfere with the pregnancy.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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