A nurse is caring for a client who is 12 hours postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Expressions of excitement

Lack of appetite

Eagerness to learn newborn care skills

Focus on the family unit and its members

Answer and Explanation

The Correct Answer is A

Choice A reason:

Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.

Choice B reason:

Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.

Choice C reason:

Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.

Choice D reason:

Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.

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Correct Answer is D

Explanation

Choice A reason:

Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •

Choice B reason:

Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •

Choice C reason:

Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •

Choice D reason:

Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.

A. Preterm birth B. Cesarean birth C. Precipitous delivery D. Frequent vaginal exams E. Mother has GBS infection

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Preterm birth is a major risk factor for neonatal sepsis, especially early-onset sepsis. Preterm babies have immature immune systems and lack antibodies to protect them against certain bacteria.

Choice B reason:

Cesarean birth is not a risk factor for neonatal sepsis by itself, unless it is associated with other factors such as prolonged rupture of membranes, maternal infection or chorioamnionitis.

Choice C reason:

Precipitous delivery is a risk factor for neonatal sepsis, especially early-onset sepsis. Precipitous delivery can cause fetal distress, hypoxia, acidosis and increased susceptibility to infection.

Choice D reason:

Frequent vaginal exams are a risk factor for neonatal sepsis, especially early-onset sepsis. Frequent vaginal exams can introduce bacteria into the amniotic fluid and increase the risk of ascending infection.

Choice E reason:

Mother has GBS infection is a risk factor for neonatal sepsis, especially early-onset sepsis. GBS (group B streptococcus) is the most common cause of early-onset neonatal sepsis and can be transmitted from the mother to the baby during labor and delivery.

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A nurse is caring for a client who is 12 hours postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

What are the risk factors for neonatal sepsis? Select all that apply. (Select All that Apply.).

Correct Answer is ["A","C","D","E"]

Explanation

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