A nurse is assisting with the care of a client who was admitted to the postpartum unit. The client is diaphoretic, skin is clammy, pulse is rapid and strong, respirations are shallow. The client reports headache, nausea, and feeling weak.
Which of the following actions should the nurse take?
Administer oxygen.
Offer an ice pack.
Provide a warm blanket.
Elevate the client’s legs.
The Correct Answer is D
Choice A rationale
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.
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Correct Answer is A
Explanation
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.
Correct Answer is B
Explanation
Choice A rationale
The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.
Choice B rationale
Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.
Choice C rationale
Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.
Choice D rationale
Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.