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: A precipitous birth is a delivery that occurs in less than 3 hours from the onset of labor. This can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after the placenta is delivered. Uterine atony is the most common cause of postpartum hemorrhage²³.
Choice B reason: A small for gestational age newborn is not a risk factor for postpartum hemorrhage. It may be associated with other conditions, such as placental insufficiency or intrauterine growth restriction, but these do not directly increase the risk of bleeding after delivery.
Choice C reason: A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. This can be a marker for congenital anomalies or placental abnormalities, but it does not increase the risk of postpartum hemorrhage by itself.
Choice D reason: Gestational hypertension is a condition where the blood pressure rises above 140/90 mm Hg after 20 weeks of pregnancy. It can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome, which can affect the clotting system and cause bleeding disorders. However, gestational hypertension alone does not increase the risk of postpartum hemorrhage unless it is associated with these severe conditions¹⁴.
Correct Answer is D
Explanation
Choice A reason:
Bloody show from the vagina is incorrect, as this finding is normal and expected in the second stage of labor. Bloody show refers to the passage of mucus and blood from the cervix, which indicates cervical dilation and effacement.
Choice B reason:
Early decelerations in the FHR is incorrect, as this finding is normal and benign in the second stage of labor. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. The nurse should continue to monitor the FHR and document the findings.
Choice C reason:
Pelvic pressure with contractions is incorrect, as this finding is normal and expected in the second stage of labor. Pelvic pressure indicates that the fetus is descending into the birth canal and that the client is ready to push.
Choice D reason:
Uterine contraction lasting 2 min is correct, as this finding is abnormal and potentially dangerous in any stage of labor. Uterine contraction lasting 2 min can indicate uterine tetany or hyperstimulation, which can cause fetal distress, placental abruption, uterine rupture, or maternal hemorrhage. The nurse should report this finding to the provider immediately and prepare to intervene as ordered.
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