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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Progressive sacral discomfort during contractions is a normal part of labor and does not necessarily require reassessment.
Choice B rationale
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal. This could signal that the labor is progressing more quickly than expected, and the nurse should reassess the client.
Choice C rationale
Intense contractions lasting 45 to 60 seconds are a normal part of active labor and do not necessarily require reassessment.
Choice D rationale
A sense of excitement and warm, flushed skin are normal emotional and physiological responses to labor and do not necessarily require reassessment.
Correct Answer is C
Explanation
Choice A rationale
Leukorrhea, or vaginal discharge, is a common occurrence in pregnancy due to hormonal changes, but it is not a specific sign of abruptio placentae.
Choice B rationale
Hypertension can be a risk factor for abruptio placentae, but it is not a direct sign of the condition.
Choice C rationale
Uterine tenderness is a common symptom of abruptio placentae. This condition, which involves the premature separation of the placenta from the uterus, can cause the uterus to become irritable and sensitive to touch.
Choice D rationale
Fetal tachycardia can be a sign of fetal distress, which could be a result of various complications in pregnancy, including abruptio placentae. However, it is not a specific sign of abruptio placentae.
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