An OB nurse is caring for an unmarried woman who is in labor. The nurse learns the client is unwilling to name the baby's father. A male visitor who comes to visit the client raises the nurse's concern that he might be violent
Which behavior would raise this concern? 1. The visitor states, "I am the baby's father."
2. The client is very anxious with the visitor present.
3. The visitor moves into the nurse's personal space when asking about the client's status.
4. The visitor sits in a chair in the corner of the client's room, rocking and smiling constantly.
3
Rationale 1: Claiming paternity does not indicate potential for violence.
Rationale 2: The client's anxiety may or may not be related to the visitor's potential for violence.
Rationale 3: The most concerning behavior is the lack of respect for the nurse's personal space when asking questions. This behavior can indicate that the person can become threatening or violent.
Rationale 4: Sitting in the corner, rocking, and smiling could be indicators of detachment from reality, but could also be benign behaviors.
Global Rationale:
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