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 B
Explanation
Choice A rationale
Limiting the client’s daily fluid intake is not recommended. Adequate hydration is important for clients with mastitis to help clear the infection and maintain milk supply.
Choice B rationale
Encouraging the client to continue to breastfeed is recommended. Breastfeeding helps to empty the breasts and reduce milk stasis, which can alleviate symptoms of mastitis.
Choice C rationale
Preparing the client for an abdominal sonogram is not relevant to the management of mastitis. Mastitis is typically diagnosed based on clinical symptoms and physical examination.
Choice D rationale
Encouraging the client to wear a bra that is loose fitting is not recommended. A well-fitting, supportive bra can help to reduce discomfort and support the breasts during mastitis.
Correct Answer is D
Explanation
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.