A nurse is caring for a client who is 12 hr 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

Answer and Explanation

The Correct Answer is A

Expressions of excitement are typical during the dependent, taking-in phase, which lasts for the first 24 to 48 hr after delivery. The client may relive and review her labor and delivery experience, and may need reassurance and validation from others.

Choice B reason:

Lack of appetite is not an expected finding during the dependent, taking-in phase, as the client may have increased hunger and thirst after delivery. The nurse should encourage adequate nutrition and hydration to promote healing and lactation.

Choice C reason:

Eagerness to learn newborn care skills is more characteristic of the dependent-independent, taking-hold phase, which begins around the third day postpartum. During this phase, the client becomes more confident and interested in caring for herself and her newborn.

Choice D reason:

Focus on the family unit and its members is more characteristic of the interdependent, letting-go phase, which occurs after the first week postpartum. During this phase, the client redefines her role within the family and society, and integrates the newborn into her life.

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Correct Answer is D

Explanation

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

A. Bloody show from the vagina B. Early decelerations in the FHR C. Pelvic pressure with contractions D. Uterine contraction lasting 2 min

Correct Answer is D

Explanation

Choice A reason:
Bloody show from the vagina is incorrect, as this finding is normal and expected in the second stage of labor. Bloody show refers to the passage of mucus and blood from the cervix, which indicates cervical dilation and eﬀacement.

Choice B reason:
Early decelerations in the FHR is incorrect, as this finding is normal and benign in the second stage of labor. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. The nurse should continue to monitor the FHR and document the findings.

Choice C reason:
Pelvic pressure with contractions is incorrect, as this finding is normal and expected in the second stage of labor. Pelvic pressure indicates that the fetus is descending into the birth canal and that the client is ready to push.

Choice D reason:
Uterine contraction lasting 2 min is correct, as this finding is abnormal and potentially dangerous in any stage of labor. Uterine contraction lasting 2 min can indicate uterine tetany or hyperstimulation, which can cause fetal distress, placental abruption, uterine rupture, or maternal hemorrhage. The nurse should report this finding to the provider immediately and prepare to intervene as ordered.

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A nurse is caring for a client who is 12 hr 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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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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