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A nurse is caring for a client who experienced a vaginal birth 12 hr 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?.

Focus on the family unit and its members.

Expressions of excitement.

Eagerness to learn newborn care skills.

Lack of appetite.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B.

Choice A rationale:

Focus on the family unit and its members is more characteristic of the “letting-go” phase.

Choice B rationale:

Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.

Choice C rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.

Choice D rationale:

Lack of appetite is not a typical characteristic of the dependent, taking in phase.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

A. The infant probably has either a congenital heart defect or an immature respiratory system. B. The infant requires immediate and aggressive interventions for survival. C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. D. The infant is adjusting well to extrauterine life.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.

Choice B rationale:

An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.

Choice C rationale:

A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.

Choice D rationale:

An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.

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A nurse is caring for a client who experienced a vaginal birth 12 hr 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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Correct Answer is A

Explanation

A nurse determines that a newborn has a 1-minute Apgar score of 5 points.What conclusion would the nurse make from this finding?.

Correct Answer is C

Explanation

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A nurse is caring for a client who experienced a vaginal birth 12 hr 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?.