(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.

Section: Questions Set C
Explanation:
(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.

(A) Incorrect application of Nagele's rule: correctly subtracted 3 months but subtracted 7 days rather than added. (B) Incorrect application of Nagele's rule: correctly subtracted 3 months but did not add 7 days. (C) Correct application of Nagele's rule: correctly subtracted 3 months and added 7 days. (D) Incorrect application of Nagele's rule: correctly subtracted 3 months but added 14 days instead of 7 days.

Section: Questions Set F
Explanation:
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

Explanation/Reference:
Explanation:
Explanation
(A) Kussmaul's respirations are associated with diabetic ketoacidosis, severe hemorrhage, peritonitis, renal failure, and uremia. (B) Tachypnea (respiratory rate >25 breaths/min) is often associated with fever.
(C) Cheyne-Stokes respiratory pattern is most often associated with increased intracranial pressure secondary to changes in pressure in the cerebral and cerebellar areas. (D) Biot's breathing is most frequently associated with spinal meningitis.