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 C

Explanation

. Lochia rubra with small clots:

Lochia rubra is the normal vaginal discharge occurring after childbirth, consisting of blood, mucus, and uterine tissue. It is expected for lochia to be present in the immediate postpartum period, and small clots are also considered normal as long as they are not excessive in size. Therefore, this finding is within the expected range for a client who is 1 hour postpartum and does not require immediate reporting to the provider.

B. Minimal perineal edema:

Perineal edema, or swelling in the perineal area, can be common after childbirth, particularly following vaginal delivery or if there was perineal trauma during labor. Some degree of perineal edema is generally expected in the immediate postpartum period and may resolve with time and appropriate care. As long as the edema is minimal and not causing significant discomfort or obstructing the assessment, it is not typically a cause for immediate concern or reporting to the provider.

C. Boggy fundus:

A boggy fundus refers to a uterus that feels soft and mushy instead of firm and well-contracted. It suggests uterine atony, which is a significant concern in the postpartum period as it can lead to excessive bleeding and postpartum hemorrhage. Therefore, a boggy fundus should be reported promptly to the provider so that interventions can be initiated to address the uterine atony and prevent complications.

D. Temperature 37.7°C (99.9°F):

A temperature of 37.7°C (99.9°F) is slightly elevated but may still fall within the normal range for the immediate postpartum period. While fever can indicate infection, a single temperature reading alone may not be sufficient to confirm an infection. It is important for the nurse to continue monitoring the client's temperature and assess for other signs and symptoms of infection before reporting to the provider. Therefore, this finding does not necessarily warrant immediate reporting unless accompanied by other concerning symptoms suggestive of infection.

A. Uterine tone soft B. Blood pressure 136/86 mm Hg C. Peripheral edema 2+ bilateral lower extremities D. Large amount of lochia rubra E. Pain rating of 3 on a scale of 0 to 10 F. Breasts soft G. Lateral deviation of the uterus

Correct Answer is ["A","D","G"]

Explanation

A. Uterine tone soft:A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.

B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.

C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.

D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.

E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.

F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.

G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.

H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.

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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

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

Correct Answer is ["A","D","G"]

Explanation

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