A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

The client talks frequently about her labor and delivery

The client hesitates to initiate contact with the baby

The client questions the nurse about the amount of formula for baby

The client request between meals snacks

Answer and Explanation

The Correct Answer is A

A. The client talks frequently about her labor and delivery is a characteristic behavior of the Taking In phase, which occurs during the first few days postpartum. During this phase, the mother is primarily focused on her own needs and recovering from childbirth. She may want to discuss her labor and delivery experience and may be more focused on rest and reflection rather than engaging with the baby.

B. The client hesitates to initiate contact with the baby is more characteristic of the Taking Hold phase, which comes after the Taking In phase. In the Taking Hold phase, the mother begins to take more responsibility for her baby’s care, though she may still seek guidance.

C. The client questions the nurse about the amount of formula for the baby indicates a more active engagement in learning about infant care, which is typical of the Taking Hold phase, where the mother starts to focus on baby care and becomes more involved.

D. The client requests between meals snacks is a sign of physical recovery and possibly an increased need for nourishment, but it does not specifically indicate being in the Taking In phase. This behavior may occur in any phase but is not a defining characteristic.

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Correct Answer is B

Explanation

A. Two fingerbreadths above the umbilicus would not be a normal finding 48 hours postpartum. By this time, the uterus should be well on its way to returning to its pre-pregnancy size and position, typically about 1 to 2 fingerbreadths below the umbilicus.

B. Two fingerbreadths below the umbilicus is the expected finding 48 hours postpartum. After birth, the uterus begins to shrink (involution) and descend into the pelvic cavity. By 48 hours, the fundus is usually 1–2 fingerbreadths below the umbilicus.

C. Four fingerbreadths below the umbilicus would be more typical of a finding several days later, after the process of involution continues. This could be a sign that the uterus is shrinking at the expected rate.

D. At the level of the umbilicus is typically expected within the first 24 hours after delivery, but by 48 hours postpartum, the fundus should have descended slightly below the level of the umbilicus.

A. Advance maternal age B. Polyhydramnios C. Macrosomia D. Preterm birth

Correct Answer is C

Explanation

A. Advanced maternal age may increase the risk of certain pregnancy complications, but it is not specifically associated with shoulder dystocia. Other factors, such as fetal size, are more directly related to shoulder dystocia.

B. Polyhydramnios (excess amniotic fluid) can sometimes be associated with complications during labor, but it is not the primary risk factor for shoulder dystocia. The condition most often involves difficulties with the fetal position or size rather than the amount of fluid.

C. Macrosomia (a large baby, typically defined as a birth weight over 8 pounds 13 ounces or 4000g) is the primary risk factor for shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders become stuck during delivery, often due to the larger size of the baby. The baby’s shoulders may be too broad to pass through the birth canal easily, which increases the likelihood of this complication.

D. Preterm birth is not a significant risk factor for shoulder dystocia. Preterm babies are typically smaller and less likely to encounter the same birth canal obstruction issues associated with shoulder dystocia.

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A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

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