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 C
Explanation
Choice A rationale
Placing the client in the knee-chest position is not appropriate for managing hypotension caused by an epidural infusion. This position does not effectively improve blood pressure.
Choice B rationale
Administering methylergonovine IM is not appropriate for managing hypotension caused by an epidural infusion. Methylergonovine is used to manage postpartum hemorrhage, not hypotension.
Choice C rationale
Giving a bolus of lactated Ringer’s is the appropriate action to manage hypotension caused by an epidural infusion. This helps to increase blood volume and improve blood pressure.
Choice D rationale
Assisting the client to empty her bladder is important, but it is not the immediate priority in managing hypotension caused by an epidural infusion.
Correct Answer is D
Explanation
Choice A rationale
Home palliative services are typically provided for patients with terminal illnesses or those requiring end-of-life care. A molar pregnancy, while serious, does not usually necessitate palliative care. Instead, the focus is on monitoring and follow-up to ensure complete removal of molar tissue and to detect any potential complications, such as gestational trophoblastic neoplasia.
Choice B rationale
Amniocentesis is a procedure used to diagnose chromosomal abnormalities and fetal infections, typically performed during the second trimester of pregnancy. It is not relevant for a patient recovering from a molar pregnancy, as there is no viable fetus involved.
Choice C rationale
Chemotherapy may be required if there is evidence of persistent gestational trophoblastic disease or choriocarcinoma, but it is not an immediate requirement for all patients recovering from a molar pregnancy. The need for chemotherapy would be determined based on follow-up hCG levels and other diagnostic tests.
Choice D rationale
Attending a support group is an important aspect of emotional and psychological recovery after a molar pregnancy. Support groups provide a space for patients to share their experiences, receive emotional support, and gain information about their condition and recovery process.