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

Is eager to review the birth experience

Begins reconnecting with their partner

Performs self-care independently

Answer and Explanation

The Correct Answer is B

The correct answer is B. The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.

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Correct Answer is D

Explanation

The correct answer is choice D. Document the client’s condition after every 15 minutes.

Choice A rationale:

Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.

Choice B rationale:

Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.

Choice C rationale:

Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.

Choice D rationale:

Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.

A. "We require informed consent for all routine treatments." B. "A family member must witness your signature on the informed consent form." C. "We can accept verbal consent unless the surgical procedure is an emergency." D. "You can sign the informed consent form after the provider explains the pros and cons of the procedure."

Correct Answer is D

Explanation

The correct answer is D. Informed consent is a process of providing information that enables the patient to make a decision to undergo a specific treatment. It requires time, patience and clarity of explanation. Consent should be obtained prior to surgery and ensure that the patient has sufficient time and information to make an informed decision. The provider should explain the indications, risks, benefits and alternatives of the procedure.

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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?

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