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.

Answer and Explanation

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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Correct Answer is D

Explanation

Rationale for Choice A:

Nipple shields are typically recommended for breastfeeding mothers experiencing nipple pain or thrush. While the client may

be experiencing some breast engorgement due to the hard and warm feeling, there is no indication of nipple pain or thrush.

Therefore, using a nipple shield is not the most appropriate recommendation in this case.

Rationale for Choice B:

Obtaining a prescription for an antibiotic is not warranted at this time. While mastitis, a breast infection, can occur

postpartum, the client's symptoms of moderate lochia rubra and firm, warm breasts are not specific enough to indicate

mastitis. Additionally, unnecessary antibiotic use should be avoided as it can contribute to antibiotic resistance.

Rationale for Choice C:

Applying a heating pad to the breasts may initially provide some comfort, but it can worsen engorgement and inflammation.

Heat stimulates milk production, which can further contribute to the client's discomfort. Applying cold compresses or ice

packs would be a more appropriate intervention for reducing inflammation and breast engorgement.

Rationale for Choice D:

Expressing milk from both breasts is the most appropriate recommendation for the client experiencing breast engorgement.

Regular milk removal helps to reduce milk build-up, alleviate engorgement, and decrease the risk of mastitis. The nurse can

teach the client proper handwashing techniques and breast massage strategies to facilitate effective milk expression.

Additionally, the nurse can encourage the client to breastfeed frequently, as this is the most efficient way to remove milk and

prevent engorgement.

Additional Notes:

The client's postpartum day (3 days) is a significant factor in considering the cause of her symptoms. Breast engorgement is

common during the first few days postpartum as milk production becomes established.

The nurse should assess the client's breastfeeding technique and ensure proper latching to prevent nipple trauma and

encourage effective milk removal.

Monitoring the client's temperature and other vital signs is crucial for identifying potential signs of infection, such as mastitis.

Providing the client with supportive measures such as comfortable bras and pain relief medications can also contribute to her

comfort and well-being.

By addressing the underlying cause of breast engorgement (milk build-up) through milk expression, the nurse can effectively

manage the client's symptoms and prevent potential complications like mastitis.

A. Swelling in both breasts. B. Cracked and bleeding nipples. C. Red and painful area in one breast. D. Increase in breast milk production.

Correct Answer is C

Explanation

Choice A rationale:

Swelling in both breasts is a common finding in breastfeeding women, especially in the early postpartum period. It is often due

to engorgement, which is caused by an oversupply of milk and/or infrequent milk removal.

While engorgement can sometimes lead to mastitis, it is not a definitive sign of the condition.

Other causes of bilateral breast swelling, such as milk stasis or plugged ducts, should also be considered.

Choice B rationale:

Cracked and bleeding nipples can be a symptom of mastitis, but they are not always present.

They can also be caused by other factors, such as improper latch, thrush, or dry skin.

It is important to assess for other signs and symptoms of mastitis, such as fever, chills, and breast tenderness, to make a

definitive diagnosis.

Choice C rationale:

A red and painful area in one breast is a classic sign of mastitis.

This is typically caused by inflammation of the breast tissue, often due to a bacterial infection.

The redness and pain are usually localized to the affected area, and may be accompanied by warmth, swelling, and firmness.

Choice D rationale:

An increase in breast milk production is not a sign of mastitis.

In fact, it is often a sign that breastfeeding is going well.

However, if the milk is not being removed effectively, it can lead to engorgement and blocked ducts, which can increase the

risk of mastitis.

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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

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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?