A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

The client puts their personal needs aside.

The client takes charge of all mothering tasks.

The client desires privacy with their newborn.

The client reviews their birth experience with others.

Answer and Explanation

The Correct Answer is D

A. The client puts their personal needs aside:

This option is not characteristic of the taking-in phase. During this phase, the mother tends to focus on her own needs and may rely on others for assistance with caregiving tasks.

B. The client takes charge of all mothering tasks:

Taking charge of all mothering tasks is more characteristic of the maternal role attainment phase, which occurs later in the postpartum period. During the taking-in phase, the mother may be less assertive in assuming full responsibility for caregiving tasks.

C. The client desires privacy with their newborn:

Incorrect. While privacy is important, it is not a specific indicator of the taking-in phase.

D. The client reviews their birth experience with others:

The client reviews their birth experience with others:This is correct. During the taking in phase, the client has a great need to talk about the labour and birth experience.

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Correct Answer is ["B","C","F"]

Explanation

A. Thromboembolism:

Thromboembolism refers to the formation of blood clots (thrombi) that break loose and travel through the bloodstream, potentially causing blockages in blood vessels (embolism). While thromboembolism is a risk in pregnancy, especially in individuals with risk factors such as obesity or a history of thromboembolic events, there are no specific indications in the scenario provided that suggest an increased risk of thromboembolism for this client.

B. Electrolyte imbalance:

The client's persistent nausea, vomiting, and ketonuria indicate significant dehydration and electrolyte imbalances. Dehydration can lead to imbalances in electrolytes such as potassium, sodium, and chloride, which are essential for proper bodily function. Laboratory findings of low potassium (hypokalemia) and elevated blood urea nitrogen (BUN) support the presence of electrolyte imbalances. These imbalances can have serious consequences for both the client and the fetus, including cardiac arrhythmias, muscle weakness, and metabolic disturbances.

C. Fetal growth restriction:

Hyperemesis gravidarum, characterized by severe nausea and vomiting leading to dehydration and weight loss, is associated with an increased risk of fetal growth restriction. Inadequate maternal nutrition and dehydration can compromise fetal growth and development, potentially leading to a smaller-than-expected size for gestational age. The client's weight loss and ketonuria further support the possibility of fetal growth restriction due to insufficient nutrient intake and placental perfusion.

D. Polyhydramnios:

Polyhydramnios refers to an excess of amniotic fluid surrounding the fetus in the uterus. While hyperemesis gravidarum and dehydration can lead to maternal complications, such as electrolyte imbalances and fetal growth restriction, they are not typically associated with an increased risk of polyhydramnios. Polyhydramnios is more commonly linked to fetal anomalies, maternal diabetes, or fetal conditions that affect swallowing or fluid regulation, none of which are evident in the provided scenario.

E. Gestational diabetes mellitus:

Gestational diabetes mellitus (GDM) is a condition characterized by high blood sugar levels during pregnancy. While GDM can lead to various complications for both the mother and the fetus, including macrosomia (large birth weight), birth injuries, and neonatal hypoglycemia, there are no indications in the scenario provided that suggest an increased risk of GDM for this client.

F. Spontaneous abortion:

Hyperemesis gravidarum, with severe nausea, vomiting, and weight loss, is associated with an increased risk of spontaneous abortion or miscarriage. Dehydration, electrolyte imbalances, and maternal malnutrition can compromise maternal and fetal well-being, potentially leading to pregnancy loss. Therefore, the client is at an increased risk of spontaneous abortion due to the severity of her symptoms and the impact on her overall health and pregnancy.

A. Previous cervical cerclage B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb) C. Previous reactive non-stress test D. Previous delivery at 37 weeks gestation

Correct Answer is A

Explanation

A. Previous cervical cerclage:

Cervical cerclage is a surgical procedure performed to reinforce the cervix in women with a history of cervical insufficiency or cervical incompetence. Cervical insufficiency is a condition where the cervix begins to dilate prematurely, leading to an increased risk of preterm birth. By placing a cervical cerclage, the risk of preterm delivery due to cervical insufficiency is reduced. Therefore, a history of previous cervical cerclage indicates an increased risk for preterm delivery in subsequent pregnancies.

B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb):

A newborn weighing 2.5 kg (5.5 lb) at birth suggests that the infant was small for gestational age (SGA). While SGA infants may be at risk for various complications, such as intrauterine growth restriction (IUGR), it does not directly indicate an increased risk for preterm delivery in subsequent pregnancies. Therefore, this choice is not indicative of preterm delivery risk.

C. Previous reactive non-stress test:

A reactive non-stress test (NST) is a reassuring finding during pregnancy and indicates that the fetus is receiving adequate oxygenation and is not under distress. While the absence of a reactive NST might indicate fetal compromise and the need for further evaluation, a previous reactive NST does not necessarily indicate an increased risk for preterm delivery.

D. Previous delivery at 37 weeks gestation:

A delivery at 37 weeks gestation is considered full-term and does not indicate an increased risk for preterm delivery. In fact, delivering at 37 weeks is within the normal range of gestational age and is not typically associated with preterm birth risk factors. Therefore, this choice does not indicate an increased risk for preterm delivery.

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A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","F"]

Explanation

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Correct Answer is A

Explanation

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