When planning the care for a small for gestational age (SG

Choice A rationale

Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.

Choice B rationale

A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.

Choice C rationale

Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.

Choice D rationale

Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.

Choice A rationale

Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.

Choice B rationale

Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.

Choice C rationale

Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.

Choice D rationale

Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.