A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?
Eagerness to learn newborn care skills
Lack of appetite
Expressions of excitement
Focus on the family unit and its members
The Correct Answer is C
Choice A reason: During the taking-in phase, the mother is often passive and may not yet show eagerness to learn newborn care skills. This phase is more about recovery and processing the birth experience.
Choice B reason: Lack of appetite might be present immediately after birth due to the exertion and possible nausea, but it is not a defining characteristic of the taking-in phase. The mother's appetite usually returns as she begins to recover.
Choice C reason: Expressions of excitement are common as the mother relives the delivery experience and begins to bond with the baby. This emotional response is part of the taking-in phase, where the mother is focused on her own experience and the reality of becoming a parent.
Choice D reason: While the focus on the family unit is important, during the taking-in phase, the mother is primarily oriented to her own needs and recovery. The focus on family members and the broader family unit becomes more prominent in the subsequent taking-hold phase.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.
Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.
Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.
Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.
Correct Answer is B
Explanation
Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.
Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.
Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.
Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.
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