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 puts their personal needs aside.

The client takes charge of all mothering tasks.

The client desires privacy with their newborn.

The client reviews their birth experience with others.

Answer and Explanation

The Correct Answer is D

A. The client puts their personal needs aside:

This option is not characteristic of the taking-in phase. During this phase, the mother tends to focus on her own needs and may rely on others for assistance with caregiving tasks.

B. The client takes charge of all mothering tasks:

Taking charge of all mothering tasks is more characteristic of the maternal role attainment phase, which occurs later in the postpartum period. During the taking-in phase, the mother may be less assertive in assuming full responsibility for caregiving tasks.

C. The client desires privacy with their newborn:

Incorrect. While privacy is important, it is not a specific indicator of the taking-in phase.

D. The client reviews their birth experience with others:

The client reviews their birth experience with others:This is correct. During the taking in phase, the client has a great need to talk about the labour and birth experience.

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Correct Answer is D

Explanation

A. Bilirubin 1 mg/dL (0.1 to 1 mg/dL):

Bilirubin levels can be elevated in conditions involving liver dysfunction or hemolysis, such as HELLP syndrome. However, a bilirubin level of 1 mg/dL falls within the normal range (0.1 to 1 mg/dL). While bilirubin levels may be elevated in some cases of HELLP syndrome, this particular value is not indicative of HELLP syndrome.

B. Uric acid 6.8 mg/dL (2 to 6.6 mg/dL):

Elevated uric acid levels are commonly seen in preeclampsia, but they are not specific to HELLP syndrome. Uric acid levels can rise due to decreased renal function and increased cell breakdown. However, while a level of 6.8 mg/dL is slightly elevated compared to the normal range (2 to 6.6 mg/dL), it alone does not confirm the presence of HELLP syndrome.

C. Fibrinogen 500 mg/dL (200 to 400 mg/dL):

Fibrinogen levels are typically increased in pregnancy, but they can be decreased in conditions associated with consumption coagulopathy, such as disseminated intravascular coagulation (DIC). However, elevated fibrinogen levels are not typically associated with HELLP syndrome. A level of 500 mg/dL is above the normal range (200 to 400 mg/dL), but this finding alone does not indicate HELLP syndrome.

D. Aspartate aminotransferase (AST) 80 units/L (4 to 20 units/L):

Aspartate aminotransferase (AST) is a liver enzyme that can be elevated in liver injury or dysfunction, which can occur in HELLP syndrome. An AST level of 80 units/L is significantly elevated compared to the normal range (4 to 20 units/L), suggesting liver dysfunction. Elevated liver enzymes are a characteristic feature of HELLP syndrome, making this finding the most indicative of HELLP syndrome among the options provided.

A. IM in right deltoid B. Subcutaneous in the right deltoid C. IM in left vastus lateralis D. Subcutaneous in the left vastus lateralis

Correct Answer is C

Explanation

A. IM in right deltoid:
The deltoid muscle is not typically used for IM injections in newborns. Additionally, the vastus lateralis muscle in the thigh is preferred over the deltoid muscle for IM injections in infants.

B. Subcutaneous in the right deltoid:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the deltoid muscle is not commonly used for subcutaneous injections in newborns.

C. IM in left vastus lateralis:
This is the correct choice. The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Administering phytonadione via IM injection in the vastus lateralis muscle allows for optimal absorption of the medication.

D. Subcutaneous in the left vastus lateralis:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the vastus lateralis muscle is typically used for IM injections rather than subcutaneous injections in infants.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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