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

Answer and Explanation

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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Correct Answer is ["B","C","D","F"]

Explanation

Choice A:

Temperature is not a priority finding to report to the provider. The newborn's temperature may vary slightly depending on the environment and the method of measurement. A 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 important to report to the provider because the newborn had a low Apgar score at 1 minute and required positive pressure ventilation and oxygen. The nurse should assess the newborn's respiratory rate, effort, breath sounds, and oxygen saturation. Any signs of respiratory distress, such as tachypnea, grunting, retractions, nasal flaring, or cyanosis, should be reported immediately.

Choice C:

Serum glucose is a critical finding to report to the provider because the newborn is at risk for hypoglycemia due to the abruptio placenta and the emergency cesarean birth. Hypoglycemia can cause neurological damage and seizures in newborns. A normal serum glucose level for a newborn is 40 to 60 mg/dL.

Choice D:

Hematocrit is a significant finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Polycythemia can cause hyperviscosity and thrombosis, while anemia can cause hypoxia and shock. A normal hematocrit level for a newborn is 42% to 65%.

Choice E:

White blood cell count is not a priority finding to report to the provider. The newborn's white blood cell count may be elevated due to the stress of birth or a maternal infection. A normal white blood cell count for a newborn is 9,000 to 30,000/mm3.

Choice F:

Hemoglobin is an important finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Hemoglobin is the main component of red blood cells that carries oxygen to the tissues. A normal hemoglobin level for a newborn is 14 to 24 g/dL.

Choice G:

Heart rate is a vital finding to report to the provider because the newborn had a non- reassuring fetal heart rate during labor and delivery. The nurse should monitor the newborn's heart rate and rhythm for any signs of bradycardia, tachycardia, or arrhythmias. A normal heart rate range for a newborn is 110 to 160 beats per minute.

A. Blood pressure. B. Gastrointestinal disturbances. C. Skin color. D. NAS score. E. Temperature. F. Oxygen saturation. G. Central nervous system disturbances. H. Respiratory rate

Correct Answer is ["B","D","F","H"]

Explanation

Choice A:

Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or a risk for complications. •

Choice B:

Gastrointestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration and poor weight gain. These can lead to electrolyte imbalance, malnutrition and failure to thrive. This choice requires immediate follow-up. •

Choice C:

Skin color is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications. •

Choice D:

NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up. •

Choice E:

Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or risk for complications. •

Choice F:

Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up. •

Choice G:

Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.

Choice H:

Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn 1 hr following birth. Exhibits Select the 5 findings that the nurse should report to the provider.

Correct Answer is ["B","C","D","F"]

Explanation

A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome. Exhibits Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).

Correct Answer is ["B","D","F","H"]

Explanation

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