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?
The client shows interest in learning about newborn care.
The client expresses concern about managing at home.
The client is eager to share her birth story.
The client is focused on her own needs and recovery.
The Correct Answer is D
Choice A rationale:
During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own
needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.
Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day
postpartum.
Choice B rationale:
Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week
postpartum.
During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to
care for her baby on her own.
Choice C rationale:
While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of
this phase.
Many mothers are still processing their experiences and may not be ready to talk about them in detail.
Choice D rationale:
The focus on personal needs and recovery is a hallmark of the taking-in phase.
The mother is typically preoccupied with physical comfort, rest, and nourishment.
She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor
due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.
Key signs of umbilical cord compression include:
Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They
are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.
Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be
a sign of cord compression, as the compression can impair placental blood flow.
Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,
including cord compression.
Immediate action is crucial when umbilical cord compression is suspected. The nurse should:
Notify the provider immediately.
Change the mother's position: This can help relieve pressure on the cord. Common positions include:
Lateral positioning (lying on the side)
Trendelenburg position (lying on the back with the head tilted down)
Knee-chest position (kneeling with the chest on the bed)
Administer oxygen to the mother: This can increase fetal oxygenation.
Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid
volume), internal fetal monitoring, or cesarean delivery.
Choice B rationale:
Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not
require intervention unless it causes significant changes in the FHR or other signs of fetal distress.
Choice C rationale:
Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are
significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report
any concerns to the provider.
Choice D rationale:
Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that
occur after the peak of a contraction is "late decelerations."
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