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?
Determine the client's temperature.
Place the client on seizure precautions.
Notify the charge nurse.
Cover the client with warm blankets.
The Correct Answer is D
The correct answer is D. Cover the client with warm blankets.
Choice A rationale:
Shaking chills are not always associated with fever, especially during the immediate postpartum period. While determining the client's temperature can rule out infection, this action does not provide immediate relief or comfort. The chills are often physiological due to hormonal and vascular changes.
Choice B rationale:
Seizure precautions are unnecessary unless additional symptoms, such as loss of consciousness or convulsions, are observed. Shaking chills are typically not indicative of a neurological event but rather a normal postpartum response.
Choice C rationale:
Notifying the charge nurse is unnecessary unless the shaking is accompanied by other abnormal findings, such as fever or prolonged chills. The immediate priority is to ensure client comfort.
Choice D rationale:
Providing warm blankets addresses the primary issue of discomfort caused by postpartum chills. This is a standard intervention to stabilize the client's body temperature and promote comfort. The action is immediate, non-invasive, and effective.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which c
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.
Choice B rationale:
Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.
Choice C rationale:
Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.
Choice D rationale:
Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.
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