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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
Choice A:
Temperature is not a finding that needs to be reported to the provider unless it is abnormally high or low. The normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B:
Respiratory findings are not a finding that needs to be reported to the provider unless they indicate respiratory distress or infection. The normal respiratory rate for a newborn is 30 to 60 breaths per minute.
Choice C:
Serum glucose is a finding that needs to be reported to the provider, as it is higher than the normal range for a newborn. The normal serum glucose level for a newborn is usually just under 2 mmol/L (or 25 mg/dL) at birth, and it will rise to over 3 mmol/L (or 60 to 100 mg/dL) within two to three days. A serum glucose level of 130 mg/dL indicates hyperglycemia, which can have various causes and complications.
Choice D:
Hematocrit is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hematocrit level for a newborn is 44% to 64%. A hematocrit level of 35% indicates anemia, which can have various causes and complications.
Choice E:
White blood cell count is not a finding that needs to be reported to the provider, as it is within the normal range for a newborn. The normal white blood cell count for a newborn is 9,000 to 30,000/mm³.
Choice F:
Hemoglobin is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hemoglobin level for a newborn is 14 to 24 g/dL. A hemoglobin level of 9 g/dL indicates anemia, which can have various causes and complications.
Correct Answer is C
Explanation
Choice A reason:
Asymmetrical breathing is not a sign of meconium aspiration syndrome (MAS). It is a sign of diaphragmatic hernia, a condition where the abdominal organs push into the chest cavity and interfere with lung development.
Choice B reason:
Born before 38 weeks gestation is not a sign of MAS. It is a risk factor for respiratory distress syndrome (RDS), a condition where the lungs are not fully developed and lack surfactant, a substance that helps keep the air sacs open.
Choice C reason:
Yellow-green staining on the umbilical cord is a sign of MAS. It indicates that the baby has passed meconium into the amniotic fluid before or during birth and may have inhaled it into the lungs. Meconium is a sticky substance that becomes the baby's first poop. It can block or irritate the airways, damage lung tissue and prevent oxygen exchange.
Choice D reason:
Acrocyanosis is not a sign of MAS. It is a normal finding in newborns where the hands and feet appear bluish due to immature circulation. It usually resolves within 24 to 48 hours after birth.
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