A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period.Which of the following actions should the nurse take?
Place the client on seizure precautions.
Cover the client with warm blankets.
Determine the client’s temperature.
Notify the charge nurse.
The Correct Answer is B
Choice A rationale
Placing the client on seizure precautions is not appropriate for shaking chills during the immediate postpartum period. Shaking chills are a common physiological response after childbirth due to hormonal changes and the body’s effort to regulate temperature. Seizure precautions are reserved for clients with a history of seizures or those exhibiting signs of a seizure disorder.
Choice B rationale
Covering the client with warm blankets is the correct action. Shaking chills are often due to the body’s attempt to regain thermal balance. Providing warmth with blankets helps to alleviate the chills and provide comfort to the client.
Choice C rationale
Determining the client’s temperature is important but not the immediate action to take. While it is necessary to monitor for fever, which could indicate an infection, the priority is to provide comfort and warmth to the client experiencing chills.
Choice D rationale
Notifying the charge nurse is not the immediate action required. The nurse should first address the client’s immediate need for warmth and comfort. If the chills persist or are accompanied by other concerning symptoms, then notifying the charge nurse would be appropriate.
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Correct Answer is C
Explanation
Choice A rationale
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Choice B rationale
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Choice C rationale
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Choice D rationale
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.
Correct Answer is A
Explanation
Choice A rationale
Measuring leg circumferences is a crucial intervention for a client with thrombophlebitis. This helps in monitoring for any increase in swelling, which can indicate worsening of the condition or the development of complications such as deep vein thrombosis (DVT). Regular measurement allows for early detection and timely intervention.
Choice B rationale
Massaging the affected extremity is contraindicated in clients with thrombophlebitis. Massage can dislodge a thrombus, leading to a potentially life-threatening pulmonary embolism. Therefore, this intervention should be avoided.
Choice C rationale
Applying cold compresses to the affected extremity is not recommended for thrombophlebitis. Cold compresses can cause vasoconstriction, which may worsen the condition by reducing blood flow and increasing the risk of clot formation.
Choice D rationale
Allowing the client to ambulate is not advisable in the acute phase of thrombophlebitis. Ambulation can increase the risk of thrombus dislodgement and subsequent pulmonary embolism. Bed rest with the affected limb elevated is usually recommended until the acute phase resolves.