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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 B

Explanation

Choice A rationale

Feeding the baby six times a day is not sufficient. Newborns typically need to be fed 8-12 times in 24 hours to ensure they receive adequate nutrition and to establish a good milk supply.

Choice B rationale

Recognizing that the baby sucking on his hands is a hunger cue is correct. This is an early sign of hunger, and responding to these cues helps ensure the baby is fed before becoming too upset.

Choice C rationale

Feeding the baby for 10 minutes on each breast may not be adequate. The duration of feeding can vary, and it is important to allow the baby to feed until they are satisfied, which may take longer than 10 minutes.

Choice D rationale

Waking the baby at least every 6 hours at night for feedings is not recommended. Newborns should be fed more frequently, typically every 2-3 hours, including during the night, to ensure they receive enough nutrition.

Correct Answer is A

Explanation

Choice A rationale

Oral contraceptives decrease the risk for endometrial cancer by regulating the menstrual cycle and reducing the frequency of ovulation, which lowers the exposure of the endometrium to estrogen.

Choice B rationale

Combined estrogen-progestin contraceptive pills typically shorten and lighten menstrual periods, rather than causing longer periods.

Choice C rationale

Medroxyprogesterone acetate injections are administered every three months, not once per month.

Choice D rationale

Diaphragms need to be replaced every 1-2 years, not every 4 years, to ensure proper fit and effectiveness.

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