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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Correct Answer is A
Explanation
Choice A reason:
All milk- and lactose-containing formulas, including breast milk, must be stopped during infancy. Soy protein is the formula of choice for newborns and infants with galactosemia. Breast milk should not be used in newborns and infants with galactosemia because it contains galactose, which they cannot metabolize properly.
Choice B reason:
Adding amino acids to the breast milk will not help the newborn with galactosemia, because the problem is not a lack of amino acids, but a deficiency of the enzyme that breaks down galactose. Amino acids are the building blocks of proteins, not sugars.
Choice C reason:
Substituting a lactose-containing formula for breast milk will worsen the condition of the newborn with galactosemia because lactose is composed of glucose and galactose. The newborns will still be exposed to galactose, which will accumulate in the blood and tissues and cause damage.
Choice D reason:
Giving the appropriate enzyme along with breast milk is not a feasible option for the newborn with galactosemia, because there is no oral enzyme replacement therapy available for this condition. The only treatment is dietary restriction of galactose.
Correct Answer is A
Explanation
Choice A reason:
This is a normal WBC for a newborn. According to MedlinePlus, the normal amount of white blood cells (WBCs) found in the bloodstream of a newborn infant is between 4,500 and 10,000 per microliter of blood. The reference ranges for WBC count established by Mayo Medical Laboratories for infants from birth to 2 years are as follows:.
• Birth: 9.0 to 30.0 x 10 9 /L.
• 1 to 7 days: 9.4 to 34.0 x 10 9 /L.
• 8 to 14 days: 5.0 to 21.0 x 10 9 /L.
• 15 days to 1 month: 5.0 to 20.0 x 10 9 /L.
• 2 to 5 months: 5.0 to 15.0 x 10 9 /L. Therefore, a newborn's WBC of 15,000 is within the normal range and does not indicate any problem.
Choice B reason:
You must call the doctor. This is not a correct answer because there is no need to call the doctor for a normal WBC in a newborn. Calling the doctor unnecessarily may cause anxiety and a waste of time and resources.
Choice C reason:
This indicates a severe infection. This is not a correct answer because a WBC of 15,000 does not necessarily indicate a severe infection in a newborn. A high WBC, also called leukocytosis, may be related to infection, but it can also be caused by other factors such as stress, inflammation, trauma, medication, or blood disorders. Moreover, the type and severity of infection can be better assessed by looking at the differential count of the different types of white blood cells (neutrophils, eosinophils, basophils, monocytes, and lymphocytes) and other signs and symptoms.
Choice D reason:
This is a lab error. This is not a correct answer because a WBC of 15,000 is not likely to be a lab error in a newborn. Lab errors can occur due to improper collection, handling, or analysis of blood samples, but they are rare and usually detected by quality control measures. A WBC of 15,000 is within the normal range for a newborn and does not require repeating the test unless there is a strong suspicion of an error or an inconsistency with other results or clinical findings.
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