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 C

Explanation

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.

A. Irrigation of a wound with antibiotic solution B. Placement of a central venous catheter C. Insertion of a nasogastric tube D. Administration of an iron injection using the Z-track technique

Correct Answer is B

Explanation

The correct answer is B. Placement of a central venous catheter.

Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.

Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.

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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

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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