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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
Correct Answer is B
Explanation
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
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