A postpartum nurse is caring for a client and their newborn.

Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

The client desires privacy with their newborn.

The client takes charge of all mothering tasks.

The client puts their personal needs aside.

The client reviews their birth experience with others.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Desiring privacy with the newborn is not specific to the taking-in phase.
Choice B rationale:
Taking charge of all mothering tasks is more indicative of the taking-hold phase.
Choice C rationale:
Putting personal needs aside is not specific to the taking-in phase.
Choice D rationale:
Reviewing the birth experience with others is characteristic of the taking-in phase.

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Correct Answer is A

Explanation

Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.

A. Intense contractions lasting 45 to 60 seconds. B. An urge to have a bowel movement during contractions. C. A sense of excitement and warm, flushed skin. D. Progressive sacral discomfort during contractions.

Correct Answer is B

Explanation

Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labor.
Choice B rationale:
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal, which may require immediate attention.
Choice C rationale:
A sense of excitement and warm, flushed skin are normal emotional and physiological responses during labor.
Choice D rationale:
Progressive sacral discomfort during contractions is a normal part of labor as the baby descends through the birth canal.

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A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Correct Answer is B

Explanation

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A postpartum nurse is caring for a client and their newborn.

Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?