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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A:
Two arteries and two veins. This is incorrect because the umbilical cord normally has only three blood vessels: one vein and two arteries. Having four blood vessels is a rare anomaly that can be associated with congenital defects. •
Choice B:
Two veins and one artery. This is incorrect because the umbilical cord normally has only one vein and two arteries. Having two veins and one artery is another rare anomaly that can also be associated with congenital defects. •
Choice C:
One artery and one vein. This is incorrect because the umbilical cord normally has two arteries and one vein. Having only one artery and one vein is a common anomaly that occurs in about 1% of singleton pregnancies and 5% of twin pregnancies. It can be associated with intrauterine growth restriction, congenital anomalies, and perinatal mortality. •
Choice D:
Two arteries and one vein. This is correct because the umbilical cord normally has two arteries and one vein. The vein carries oxygenated blood from the placenta to the fetus, while the arteries carry deoxygenated blood from the fetus to the placenta. The umbilical cord also contains Wharton's jelly, which is a gelatinous substance that protects the blood vessels from compression.
Correct Answer is D
Explanation
Choice A reason:
Protamine sulfate is an antidote for heparin overdose, not magnesium sulfate toxicity.
Choice B reason:
Naloxone is an antidote for opioid overdose, not magnesium sulfate toxicity.
Choice C reason:
Flumazenil is an antidote for benzodiazepine overdose, not magnesium sulfate toxicity.
Choice D reason:
Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is used to treat preeclampsia and prevent seizures, but it can cause respiratory depression, hypotension, and cardiac arrhythmias if given in excess. Calcium gluconate reverses the effects of magnesium by stabilizing the cell membrane and increasing the contractility of the heart.
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