A nurse is caring for a client who is 12 hr 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
Expressions of excitement are typical during the dependent, taking-in phase, which lasts for the first 24 to 48 hr after delivery. The client may relive and review her labor and delivery experience, and may need reassurance and validation from others.
Choice B reason:
Lack of appetite is not an expected finding during the dependent, taking-in phase, as the client may have increased hunger and thirst after delivery. The nurse should encourage adequate nutrition and hydration to promote healing and lactation.
Choice C reason:
Eagerness to learn newborn care skills is more characteristic of the dependent-independent, taking-hold phase, which begins around the third day postpartum. During this phase, the client becomes more confident and interested in caring for herself and her newborn.
Choice D reason:
Focus on the family unit and its members is more characteristic of the interdependent, letting-go phase, which occurs after the first week postpartum. During this phase, the client redefines her role within the family and society, and integrates the newborn into her life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Placing the client in a lateral position is the first action the nurse should take, as it can improve maternal and fetal circulation by relieving pressure on the inferior vena cava. The client's blood pressure is low, which can indicate hypotension due to epidural anesthesia or supine hypotension syndrome.
Choice B reason:
Notifying the provider is an important action, as it can facilitate further interventions and monitoring for the client and the fetus. However, this is not the first action the nurse should take, as it does not address the immediate problem of hypotension.
Choice C reason:
Increasing IV fluid rate is an important action, as it can expand blood volume and increase blood pressure. However, this is not the first action the nurse should take, as it may not be effective if the client is in a supine position.
Choice D reason:
Elevating the legs is an important action, as it can enhance venous return and increase blood pressure. However, this is not the first action the nurse should take, as it may worsen supine hypotension syndrome by increasing pressure on the inferior vena cava.
Correct Answer is A
Explanation
Choice A reason:
Checking the consistency of the client's uterine fundus is the first action the nurse should take, as it can indicate the cause of excessive bleeding. A boggy or soft fundus indicates uterine atony, which is the most common cause of postpartum hemorrhage. The nurse should massage the fundus until it becomes firm and contracted.
Choice B reason:
Having the client use the bedpan to urinate is an important action, as a full bladder can displace the uterus and prevent it from contracting properly. However, this is not the first action the nurse should take, as it does not address the immediate source of bleeding.
Choice C reason:
Increasing the client's fluid intake is an important action, as it can help replace fluid loss and prevent hypovolemia and shock. However, this is not the first action the nurse should take, as it does not stop the bleeding.
Choice D reason:
Preparing to administer oxytocic medication is an important action, as it can stimulate uterine contractions and reduce bleeding. However, this is not the first action the nurse should take, as it requires a provider's prescription and may not be necessary if fundal massage is effective.
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