A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Tolerates physical discomforts

Performs self-care independently

Begins reconnecting with their partner

Is eager to review the birth experience

Answer and Explanation

The Correct Answer is D

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Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

A. Changing the appliance on a new colostomy B. Performing indwelling urinary catheter care C. Demonstrating how to use an incentive spirometer D. Measuring the depth of a stage 3 pressure injury

Correct Answer is B

Explanation

Choice A Reason:

A. Changing the appliance on a new colostomy requires specialized knowledge of ostomy care and assessment, including assessing stoma health and proper technique.

Choice B Reason:

This is an appropriate task to delegate to an AP. APs are trained to perform basic tasks like catheter care under the supervision of a nurse.

Choice C Reason

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient's ability to perform the procedure correctly, which requires clinical judgment and teaching skills and should not be delegated to an AP.

Choice D Reason:

This task involves assessing the wound, which requires clinical judgment and should be done by a nurse, not an AP.

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A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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