QUESTION: "In response to the nurse's question about how she is feeling, the client replies that she is tired, sore, and hungry. She then begins to relate her birth experience. Based on the assessment data, the nurse determines that the client is in the phase of postpartal psychological adaptation known as which of the following?"
CHOICES
( X ) a.) Reaching out.
( O ) b.) Taking in.
( X ) c.) Taking hold.
( X ) d.) Letting go.
RATIONALE: The client is in the taking-in phase for up to 3 days after birth. During this time, food and sleep are a major focus for the client. In addition, she works through the birth experience to sort out reality from fantasy and to clarify any misunderstandings. Reaching out is not an identified phase of postpartal psychological adaptation. The taking-hold phase is the second phase of postpartal psychological adaptation occurring by about the second or third postpartum day and demonstrated by a greater focus on the neonate and less focus on the self. The letting-go phase is the final phase occurring at about 7 to 10 days postpartum and continuing through the child's growth years and demonstrated by grief and readjustment of relationships. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
