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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.
Choice B rationale:
Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.
Choice C rationale:
Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.
Choice D rationale:
While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.
Additional notes:
The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.
Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.
Correct Answer is B
Explanation
The correct answer is choice **b. Presence of phosphatidylglycerol (PG).**
**
Choice A rationale:
** A biophysical profile score of 8 indicates that the fetus is generally doing well, but it does not specifically indicate lung maturity. This score combines several factors, such as fetal movements and amniotic fluid volume, but it is not solely indicative of lung development.
**
Choice B rationale:
** The presence of phosphatidylglycerol (PG) is a critical indicator of fetal lung maturity. PG is a phospholipid found in amniotic fluid and is essential for the production of surfactant, which helps keep the alveoli in the lungs open, reducing the risk of respiratory distress syndrome after birth.
**
Choice C rationale:
** A non-stress test (NST) with reassuring results suggests that the fetus is not under stress, but it does not provide information about lung maturity. The NST primarily evaluates the fetal heart rate response to fetal movements.
**
Choice D rationale:
** The estriol level is a marker for placental function and fetal well-being, but it is not directly related to lung maturity. Estriol levels are more commonly associated with monitoring for potential complications in pregnancy rather than assessing lung development.
Phosphatidylglycerol (PG) is the most specific marker for confirming that the fetal lungs have matured, ensuring that the baby is ready for breathing outside the womb.
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