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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Answer: D. Blurry vision
Rationale: Blurry vision, along with yellow-green halos around lights, is a sign of digoxin toxicity that can occur when the serum level of the drug exceeds 2 ng/mL. Other signs of digoxin toxicity include nausea, vomiting, anorexia, confusion, arrhythmias, and bradycardia. Tinnitus, constipation, and joint pain are not related to digoxin toxicity.
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