A nurse is caring for a client who experienced a vaginal birth 12 hr 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?.

The correct answer is choice C.

Choice A rationale:

While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.

Choice B rationale:

Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.

Choice C rationale:

Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.

Choice D rationale:

A full head-to-toe assessment is important, but it’s not the immediate priority following birth.

The correct answers are choices B, E, and F.

Choice A rationale:

Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.

Choice B rationale:

Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.

Choice C rationale:

Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.

Choice D rationale:

Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.

Choice E rationale:

Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.

Choice F rationale:

Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.