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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?

A.

Administer oxygen.

B.

Offer an ice pack.

C.

Provide a warm blanket.

D.

Elevate the client’s legs.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice B rationale

Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice C rationale

Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice D rationale

Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.

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.

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