A nurse is caring for a client who experienced a vaginal birth 20 hours ago.
The nurse recognizes the client is in the taking-in phase of maternal postpartum adjustment.
Which finding should the nurse expect during this phase?
Lack of appetite.
Eagerness to learn newborn care skills.
Discussion of birth experience.
Reconnection with her partner.
The Correct Answer is C
Choice A rationale
Lack of appetite is not typically associated with the taking-in phase of maternal postpartum adjustment. During this phase, the mother is more focused on her own needs, such as rest and recovery from childbirth.
Choice B rationale
Eagerness to learn newborn care skills is more characteristic of the taking-hold phase, which follows the taking-in phase. In the taking-in phase, the mother is more passive and dependent, focusing on her own needs.
Choice C rationale
Discussion of the birth experience is a common behavior during the taking-in phase. The mother often wants to talk about her labor and delivery experience as a way to process and integrate the event.
Choice D rationale
Reconnection with her partner is not a primary focus during the taking-in phase. The mother is more focused on her own recovery and the immediate needs of her newborn.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale
The rubella vaccine should not be taken during pregnancy. It is a live attenuated vaccine, and there is a theoretical risk of harm to the developing fetus. Therefore, it is recommended to receive the vaccine before pregnancy.
Choice B rationale
The rubella vaccine is not recommended during each pregnancy. It is typically given as part of the MMR (measles, mumps, rubella) vaccine series in childhood, and immunity is usually lifelong. A booster dose is not needed during each pregnancy.
Choice C rationale
The rubella vaccine is not related to the Rh status of the baby. The vaccine is given to prevent rubella infection, which can cause serious birth defects if contracted during pregnancy.
Choice D rationale
The correct statement is that the client should avoid pregnancy for 28 days after receiving the rubella vaccine. This is to ensure that the live attenuated virus does not pose a risk to a developing fetus.
Correct Answer is C
Explanation
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.
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