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?
The client shows interest in learning about newborn care.
The client expresses concern about managing at home.
The client is eager to share her birth story.
The client is focused on her own needs and recovery.
The Correct Answer is D
Choice A rationale:
During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own
needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.
Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day
postpartum.
Choice B rationale:
Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week
postpartum.
During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to
care for her baby on her own.
Choice C rationale:
While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of
this phase.
Many mothers are still processing their experiences and may not be ready to talk about them in detail.
Choice D rationale:
The focus on personal needs and recovery is a hallmark of the taking-in phase.
The mother is typically preoccupied with physical comfort, rest, and nourishment.
She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is
compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.
Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically
recover quickly to the baseline fetal heart rate after the compression is relieved.
Several factors can contribute to umbilical cord compression, including:
Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.
Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone
to compression.
Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during
contractions.
Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.
Choice B rationale:
Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable
decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.
Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can
then trigger a decrease in fetal heart rate.
Choice C rationale:
The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate
may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.
Choice D rationale:
The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause
variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late
decelerations.
Correct Answer is A
Explanation
Choice A rationale:
Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's
thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This
triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to
fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.
Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result
from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or
severe, and they often precede a rise in temperature.
Choice B rationale:
Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be
present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign
of endometritis, it's not considered a primary manifestation.
Choice C rationale:
Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of
endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,
constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.
Choice D rationale:
Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual
vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all
women with endometritis will have abnormal discharge.
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