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
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.
Correct Answer is D
Explanation
Choice A rationale
Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice B rationale
Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.
Choice C rationale
Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice D rationale
Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety.