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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Fundus soft, 2 fingerbreadths below the umbilicus is incorrect, as this finding indicates uterine atony and subinvolution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A soft or boggy fundus can increase the risk of hemorrhage and infection.

Choice B reason: Fundus firm, 1 fingerbreadth below the umbilicus is correct, as this finding indicates normal uterine contraction and involution. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A firm and midline fundus can prevent excessive bleeding and promote healing.

Choice C reason: Fundus firm, 4 fingerbreadths above the umbilicus is incorrect, as this finding indicates a higher than expected fundal height for a client who is 24 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.

Choice D reason: Fundus soft, to the right of the umbilicus is incorrect, as this finding indicates uterine atony and bladder distension. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection.

A. The client is Rh negative and the newborn is Rh positive. B. The client is Rh negative and the newborn is Rh negative. C. The client is Rh positive and the newborn is Rh positive. D. The client is Rh positive and the newborn is Rh negative.

Correct Answer is A

Explanation

Choice A reason: The client is Rh negative and the newborn is Rh positive is correct, as this finding indicates a risk of Rh incompatibility and sensitization. Rh incompatibility occurs when the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause maternal antibodies to atack the fetal red blood cells. Sensitization occurs when the maternal antibodies cross the placenta and enter the fetal circulation, which can cause hemolytic disease of the newborn. The nurse should administer Rho(D) immune globulin to prevent sensitization and protect future pregnancies.

Choice B reason: The client is Rh negative and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.

Choice C reason: The client is Rh positive and the newborn is Rh positive is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-positive blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.

Choice D reason: The client is Rh positive and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If the mother has Rh-positive blood and the baby has Rh- negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is A

Explanation

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