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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Iron is not poorly absorbed in infants; in fact, infants absorb iron quite efficiently. Breast milk contains a small amount of iron, but it is highly bioavailable and well-absorbed. When switching to formula, it is important to use iron-fortified options to prevent iron deficiency anemia.
Choice B Reason:
While iron is essential for overall growth and development, including bone growth, it is not the primary reason for emphasizing iron in infant nutrition. The key concern with iron, especially when transitioning from breastfeeding, is the prevention of iron deficiency anemia, which can affect cognitive and motor development.
Choice C Reason:
This is the correct information to include in the teaching. Infants are born with a reserve of iron that begins to deplete around 4 to 6 months of age. It is crucial to introduce iron-fortified formula at this time to ensure the infant continues to receive adequate iron for development and to prevent iron deficiency anemia.
Choice D Reason:
Iron does play a role in the development of the nervous system, which can indirectly affect vision, but it is not specifically known for facilitating the development of vision in infants. The primary concern with iron intake in infants relates to its role in preventing anemia and supporting overall growth and development.
Correct Answer is B
Explanation
Choice A reason:
Immunization for rubella in the third trimester is not recommended because live vaccines are contraindicated during pregnancy due to the theoretical risk to the fetus.
Choice B reason:
The recommended time for rubella immunization is shortly after giving birth. This timing is advised because the vaccine contains a live virus, which could potentially harm the fetus if given during pregnancy. By waiting until after the delivery, there is no risk to the newborn, and the mother can develop immunity before any subsequent pregnancies.
Choice C reason:
While it is important for a woman to have immunity to rubella before getting pregnant, the immunization should not be given during the time she is trying to conceive. Women are advised to avoid pregnancy for at least 28 days after receiving the MMR vaccine, which includes the rubella component, due to the live virus in the vaccine.
Choice D reason:
Immunization for rubella should not be given immediately upon finding out that the client does not have immunity during the first trimester. As mentioned, live vaccines are contraindicated during pregnancy, and the immunization should be postponed until after the birth of the baby.
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