A nurse is caring for a client who is 12 hours postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?
Expressions of excitement
Lack of appetite
Eagerness to learn newborn care skills
Focus on the family unit and its members
The Correct Answer is A
Choice A reason:
Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.
Choice B reason:
Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.
Choice C reason:
Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.
Choice D reason:
Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
FAS is caused by alcohol, and NAS is caused by opioids. This is the correct answer because FAS stands for fetal alcohol syndrome, which is a condition that affects the development of a baby when the mother drinks alcohol during pregnancy. NAS stands for neonatal abstinence syndrome, which is a group of problems that can happen when a baby is exposed to opioid drugs for a length of time while in their mother's womb.
Choice B reason:
FAS and NAS are both incurable. This is incorrect because FAS and NAS are not diseases, but conditions that result from prenatal exposure to substances. FAS and NAS can cause various physical, mental, and behavioral problems in the baby, some of which may be permanent, but others may be improved with early intervention and treatment.
Choice C reason:
FAS is caused by analgesics and NAS is caused by NSAIDs. This is incorrect because analgesics are painkillers, and NSAIDs are nonsteroidal anti-inflammatory drugs. Neither of these types of drugs is known to cause FAS or NAS. However, some analgesics, such as codeine and oxycodone, are opioids and can cause NAS if used by pregnant women.
Choice D reason:
FAS and NAS are both curable. This is incorrect because FAS and NAS are not diseases, but conditions that result from prenatal exposure to substances. FAS and NAS can cause various physical, mental, and behavioral problems in the baby, some of which may be permanent, but others may be improved with early intervention and treatment. However, there is no cure for FAS or NAS.
Correct Answer is ["B","C","D"]
Explanation
Choice A:
Lidocaine gel to the umbilical stump is not a medication that the nurse should expect to administer to a newborn immediately following birth. Lidocaine gel is a topical anesthetic that is used to numb the skin before procedures such as injections or sutures. It is not indicated for the umbilical stump, which does not require any anesthesia.
Choice B:
Hepatitis B immunization is a medication that the nurse should expect to administer to a newborn immediately following birth. Hepatitis B is a viral infection that can cause liver damage and cancer. The immunization protects the newborn from contracting the infection from the mother or other sources. The immunization is given as an intramuscular injection in the anterolateral thigh within 12 hours of birth.
Choice C:
Phytonadione injection is a medication that the nurse should expect to administer to a newborn immediately following birth. Phytonadione is also known as vitamin K, which is essential for blood clotting. Newborns have low levels of vitamin K at birth, which puts them at risk of bleeding disorders such as hemorrhagic disease of the newborn. The injection is given as a single dose of 0.5 to 1 mg in the vastus lateralis muscle within 1 hour of birth.
Choice D:
Antibiotic ophthalmic ointment is a medication that the nurse should expect to administer to a newborn immediately following birth. Antibiotic ophthalmic ointment prevents eye infections caused by bacteria such as gonorrhea or chlamydia, which can be transmitted from the mother during delivery. The ointment is applied to both eyes within 1 hour of birth.
Choice E:
Haemophilus influenzae type b vaccine (Hib) is not a medication that the nurse should expect to administer to a newborn immediately following birth. Hib is a bacterial infection that can cause meningitis, pneumonia, and other serious illnesses. The vaccine protects the newborn from Hib infection, but it is not given at birth. The vaccine is part of the routine immunization schedule and is usually given at 2, 4, and 6 months of age.
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