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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage the client to apply a warm pack to the perineum for discomfort.
While warm packs can provide comfort and promote relaxation for some types of perineal discomfort, they may not be suitable for a third-degree perineal laceration. In fact, applying heat directly to the perineum may exacerbate swelling and increase discomfort in this particular case. Therefore, it is not the most appropriate intervention for this client.
B. Prepare the client for a pudendal nerve block.
A pudendal nerve block is typically used during labor or for specific procedures (such as episiotomy repair) to provide pain relief. It is not a routine intervention for postpartum perineal lacerations.
C. Apply hydrogel pads to the perineum every 4 hr.
While hydrogel pads can provide some relief for perineal discomfort, they are not typically used specifically for third-degree perineal lacerations. These types of lacerations require medical intervention and repair rather than solely relying on over-the-counter remedies like hydrogel pads. Therefore, this intervention may not address the underlying issue effectively.
D. Place a witch hazel pad on the client's perineal pad after each voiding.
Witch hazel pads can provide soothing relief to the perineum and help reduce swelling and discomfort after childbirth. They have a cooling effect and can also have mild astringent properties, which may aid in promoting healing.Placing a witch hazel pad on the perineal pad after each voiding helps ensure that the perineum remains clean and that the client experiences continuous relief from discomfort
Correct Answer is ["A","D","G"]
Explanation
A. Uterine tone soft:A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.
B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.
C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.
D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.
E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.
F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.
G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.
H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.
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