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 D
Explanation
Choice A rationale
Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.
Choice B rationale
Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.
Choice C rationale
Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.
Choice D rationale
Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.
Correct Answer is C
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important for understanding their overall health and access to resources, but it is not directly related to providing information about contraception.
Choice B rationale
Selecting the best method of contraception for the client is not the nurse’s role. The decision should be made by the client based on their individual preferences and health considerations.
Choice C rationale
Performing unbiased teaching is essential for providing accurate and comprehensive information about available methods of contraception. The nurse should present all options without imposing personal beliefs or preferences.
Choice D rationale
Providing information on all available methods is important, but it should be done in an unbiased manner. The nurse should ensure that the client has all the necessary information to make an informed decision.