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?

Lack of appetite

Eagerness to learn newborn care skills

Expressions of excitement

Focus on the family unit and its members

Answer and Explanation

The Correct Answer is C

A) Lack of appetite: During the dependent, taking in phase of maternal postpartum adjustment, the client is primarily focused on her own needs, particularly physical recovery and rest. She may not have a significant appetite due to fatigue, discomfort, or hormonal changes. However, expressions of excitement are more characteristic of this phase.
B) Eagerness to learn newborn care skills: While learning newborn care skills is an essential part of the postpartum period, it is more characteristic of the independent, taking hold phase. In the dependent, taking in phase, the client is more focused on her own needs, relying on others for assistance and care.
C) Expressions of excitement: During the dependent, taking in phase, the client is excited about her newborn and the experience of motherhood. She may express enthusiasm and interest in bonding with the baby, even though she may also rely heavily on others for support and care.
D) Focus on the family unit and its members: While the family unit is important, during the dependent, taking in phase, the client's primary focus is on her own physical recovery and rest. She may not yet be fully engaged in family dynamics or focused on the needs of other family members.

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Correct Answer is B

Explanation

A) Nausea: Nausea is a common side effect of magnesium sulfate therapy but is not necessarily indicative of magnesium sulfate toxicity. It is important to monitor for nausea, but it is not the most critical finding to indicate toxicity.
B) Respiratory depression: Respiratory depression is a severe sign of magnesium sulfate toxicity and should be reported to the provider immediately. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which is a potentially life-threatening complication.
C) Drowsiness: Drowsiness is a common side effect of magnesium sulfate therapy, especially at therapeutic levels. However, it is not necessarily indicative of magnesium sulfate toxicity. While drowsiness should be monitored, it is not as critical as respiratory depression in indicating toxicity.
D) Facial flushing: Facial flushing is a common side effect of magnesium sulfate therapy and is not typically associated with magnesium sulfate toxicity. While it can be uncomfortable for the patient, it is not a severe indication of toxicity compared to respiratory depression.

A. Contractions are strong in intensity B. Client reports feeling contractions in lower back C. Contractions occurring every 3 to 5 min D. Contractions lasting longer than 90 seconds

Correct Answer is D

Explanation

A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.

B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.

C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.

D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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