A nurse is caring for a client who experienced a vaginal birth 20 hours ago. The nurse recognizes the client is in the taking-in phase of maternal postpartum adjustment. Which finding should the nurse expect during this phase?
Lack of appetite.
Eagerness to learn newborn care skills.
Discussion of birth experience.
Reconnection with her partner.
The Correct Answer is C
Choice A rationale
Lack of appetite is not typically associated with the taking-in phase of maternal postpartum adjustment. During this phase, the mother is more focused on her own needs, such as rest and recovery from childbirth.
Choice B rationale
Eagerness to learn newborn care skills is more characteristic of the taking-hold phase, which follows the taking-in phase. In the taking-in phase, the mother is more passive and dependent, focusing on her own needs.
Choice C rationale
Discussion of the birth experience is a common behavior during the taking-in phase. The mother often wants to talk about her labor and delivery experience as a way to process and integrate the event.
Choice D rationale
Reconnection with her partner is not a primary focus during the taking-in phase. The mother is more focused on her own recovery and the immediate needs of her newborn.
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Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Washing hands before and after perineal care or voiding is essential to prevent infection. Proper hand hygiene reduces the risk of introducing bacteria to the perineal area, which is particularly vulnerable to infection postpartum.
Choice B rationale
Leaving the current pad on until it is fully saturated is not recommended. Changing pads frequently helps to maintain cleanliness and reduce the risk of infection. A saturated pad can harbor bacteria and increase the risk of infection.
Choice C rationale
Wiping the perineum thoroughly with a back-and-forth motion is not recommended. Instead, the perineum should be wiped from front to back to prevent the spread of bacteria from the rectal area to the perineal area, reducing the risk of infection.
Choice D rationale
Using a perineal squeeze bottle to cleanse the perineum is recommended. It helps to gently clean the area without causing irritation or discomfort. The warm water can also provide soothing relief to the perineal area.
Choice E rationale
Applying ice or cold packs to the perineum can help to reduce swelling and provide pain relief. The cold temperature constricts blood vessels, reducing inflammation and numbing the area to alleviate discomfort.
Correct Answer is D
Explanation
Choice A rationale
Using a bladder scanner to assess for urinary retention is a non-invasive and appropriate intervention. It helps determine the volume of urine in the bladder and can guide further management. This method avoids unnecessary catheterization and reduces the risk of infection.
Choice B rationale
Catheterizing to empty the bladder is a common intervention for urinary retention. However, it should be done with caution and only when necessary to avoid the risk of infection. In this scenario, it is not contraindicated but should be considered after other non-invasive methods have been tried.
Choice C rationale
Placing peppermint oil on a cotton ball and placing it in the urinary “hat” while the client is on the toilet is a non-invasive method that can help stimulate urination through the scent of peppermint. This method is safe and can be effective for some clients.
Choice D rationale
Assisting the client back to bed and telling her to try to void again in 2 hours is contraindicated because it delays the intervention for a distended bladder. A distended bladder can cause discomfort and potential complications, so timely intervention is necessary.