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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.
Correct Answer is D
Explanation
Choice A rationale
Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice B rationale
Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.
Choice C rationale
Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice D rationale
Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety.