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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.

A. Single palmar creases. B. Rust-stained urine. C. Transient circumoral cyanosis. D. Subconjunctival hemorrhage.

Correct Answer is A

Explanation

The correct answer is choice A. Single palmar creases.

Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.

Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.

Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.

Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?

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