A nurse is planning care for a client in the postpartum unit. Which of the following 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 identify individual family member roles.
The client will have adequate nutritional intake.
The Correct Answer is D
Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Uterine hypertonicity is associated with labor complications, not placenta previa.
Choice B rationale:
A persistent headache is not a typical symptom of placenta previa.
Choice C rationale:
A firm, rigid abdomen is a sign of a possible uterine rupture, not placenta previa.
Choice D rationale:
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is correct.
Correct Answer is D
Explanation
Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.
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