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
Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.
Choice B rationale
Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.
Choice C rationale
Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.
Choice D rationale
Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.
Correct Answer is D
Explanation
Choice A rationale
Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.
Choice B rationale
Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.
Choice C rationale
Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.
Choice D rationale
Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .