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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.
Choice A rationale:
Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.
Choice B rationale:
Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.
Choice D rationale:
While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.
Correct Answer is A
Explanation
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.