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.

Answer and Explanation

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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Correct Answer is C

Explanation

Step 1: According to Naegele’s rule, we start with the first day of the last menstrual period, which is June 212.
Step 2: We then subtract three months, which gives us March 212.
Step 3: Finally, we add seven days, which gives us March 282. So, the estimated date of delivery in the next year is March 28.

A. Administer a tocolytic medication B. Wrap the cord in a sterile towel and moisten with warm sterile normal saline C. Apply oxygen via facemask to the client D. Exert upward pressure on the presenting part

Correct Answer is D

Explanation

The correct answer is choiced. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first.This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is pregnant and whose last menstrual cycle started June 21. What is the estimated date of delivery in the next year?

Correct Answer is C

Explanation

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Correct Answer is D

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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?