A nurse is planning care for a client in the postpartum unit.
What goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
The client will demonstrate proper bathing of the infant.
The client will verbalize appropriate car seat safety.
The client will have adequate nutritional intake.
The client will identify necessary family roles.
The Correct Answer is C
Choice A rationale
While demonstrating proper bathing of the infant is an important skill for new mothers, it is not typically a primary goal during the taking-in phase. This phase is characterized by the mother’s need to review her birth experience and begin to process her new role.
Choice B rationale
Verbalizing appropriate car seat safety is important, but it is not a primary goal during the taking-in phase. This phase is more focused on the mother’s internal processing of her birth experience.
Choice C rationale
This is the correct answer. Having adequate nutritional intake is a key goal during the taking-in phase. Good nutrition is essential for healing and recovery after childbirth, as well as for breastfeeding.
Choice D rationale
Identifying necessary family roles is an important part of adjusting to parenthood, but it is not a primary goal during the taking-in phase. This phase is more about the mother’s personal adjustment and recovery.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uterine hypertonicity is not typically associated with placenta previa. Hypertonicity refers to an overly active uterus with contractions that are too strong, too long, or too close together.
Choice B rationale
Painless vaginal bleeding is a classic symptom of placenta previa. The bleeding is usually bright red and can be heavy.
Choice C rationale
Persistent headache is not a typical symptom of placenta previa. It is more commonly associated with conditions like preeclampsia.
Choice D rationale
Fetal distress is not a direct symptom of placenta previa, but it can occur if the placenta is not providing enough oxygen and nutrients to the fetus.
Correct Answer is A
Explanation
Choice A rationale
Hypotension is a known adverse effect of epidural analgesia. The epidural can block sympathetic nerve fibers, which can lead to vasodilation and a drop in blood pressure.
Choice B rationale
A maternal temperature of 37.4 C (99.4 F) is within the normal range and is not typically a cause for concern. While epidural analgesia can potentially cause a slight increase in body temperature, a significant fever is not a common side effect.
Choice C rationale
Polyuria, or excessive urination, is not a typical side effect of epidural analgesia. While the epidural can affect nerve signals to the bladder, it does not typically cause the kidneys to produce more urine.
Choice D rationale
A fetal heart rate of 152/min is within the normal range for a fetus (110-160 beats per minute). While epidural analgesia can potentially affect the baby’s heart rate if it causes significant maternal hypotension, a heart rate of 152/min is not indicative of a problem. CytomegalovirusCytomegalovirus Explore
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