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 D

Explanation

After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.

A. Document the infiltration. B. Elevate the arm. C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

Choice A Reason:

Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.

Choice B Reason:

Elevating the arm can help reduce swelling, but it should come after stopping the infusion.

Choice C Reason:

Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.

Choice D Reason:

Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.

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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 caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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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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