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","G","H"]
Explanation
Choice A rationale
Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.
Choice C rationale
A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
Choice D rationale
A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.
Choice E rationale
Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
Choice F rationale
Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.
Choice G rationale
A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
Choice H rationale
Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly.
Correct Answer is B
Explanation
Choice A rationale
Not wanting to call the baby by name until the baby is born can be a cultural or personal preference and does not necessarily indicate effective adaptation to the new role. It may reflect a cautious approach to the pregnancy but does not provide evidence of active preparation or involvement.
Choice B rationale
Starting to paint the baby’s room is a proactive behavior that indicates the partner is preparing for the baby’s arrival. It shows that the partner is taking steps to create a welcoming environment for the baby, which is a positive sign of adaptation to the new role.
Choice C rationale
Looking forward to sharing hobbies with the child in the future is a positive indication of the partner’s excitement and anticipation for the baby’s growth and development. However, it does not directly reflect immediate preparation or involvement in the pregnancy.
Choice D rationale
Waiting until the baby is born to share the news with coworkers may reflect a cautious approach to the pregnancy but does not indicate active involvement or preparation for the baby’s arrival. It may be a personal preference but does not demonstrate effective adaptation to the new role.