A nurse is assisting with the care of a client who is using paced breathing during the first stage of labor.
The client says she feels lightheaded and her fingers are tingling.
Which of the following actions should the nurse take?

Choice A rationale:

To prevent thrombophlebitis in a postpartum client following a cesarean birth, it is important to promote good circulation and prevent stasis of blood in the lower extremities. Placing pillows under the client's knees while she is resting in bed helps elevate the legs slightly and promotes better venous return, reducing the risk of thrombophlebitis. This position facilitates improved circulation and is a recommended practice.

Choice B rationale:

Applying hot moist soaks to the client's lower legs is not a recommended intervention to prevent thrombophlebitis. In fact, heat can increase inflammation and may worsen the condition. This option would not contribute to the client's plan of care for thrombophlebitis prevention.

Choice C rationale:

Assisting the client to ambulate in the hallway is a good practice to prevent thrombophlebitis, but it may not be suitable for a client who is only 1 day postpartum following a cesarean birth. Early ambulation is encouraged but should be done gradually and at the client's own pace to avoid undue stress on the incision site. Placing pillows under the knees while resting in bed is a more appropriate initial intervention.

Choice D rationale:

Keeping the client on bed rest is not the best option for preventing thrombophlebitis in a postpartum client. Immobility can increase the risk of stasis and clot formation. Promoting circulation, such as elevating the legs with pillows, is a more effective strategy to reduce the risk of thrombophlebitis.

Choice A rationale:

Placing the client on seizure precautions is not the appropriate action in this scenario. Shaking chills during the immediate postpartum period are not indicative of a seizure. Seizure precautions involve measures like protecting the client from injury during a seizure, such as moving them to a safe area and providing a padded bed or mattress. This is not relevant to the client's current situation of shaking chills.

Choice C rationale:

Covering the client with warm blankets may provide comfort and help raise body temperature if the client is experiencing chills due to being cold. However, it does not address the underlying cause of the shaking chills. The nurse should first assess the client's temperature to determine the cause of the chills before implementing interventions.

Choice D rationale:

Notifying the charge nurse is not the immediate action needed when a client is experiencing shaking chills. The primary responsibility of the nurse in this situation is to assess and identify the cause of the chills. Once the cause is determined, appropriate interventions can be initiated. It's essential to focus on the immediate assessment of the client's condition.