Explanation
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.

Explanation
(A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus.
Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. (B) The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. (C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. (D) Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.

(A) The child with asthma may not have fever unless there is an underlying infection. (B) Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. (C) All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. (D) Coughing and wheezing are not early signs of difficulty.

Explanation
(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis.
(B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.

Explanation
(A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses' Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.