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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale:

If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.

Choice B rationale:

This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.

Choice C rationale:

If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.

Choice D rationale:

If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.

A. Blood pressure. B. Cerebral manifestations. C. Fetal heart rate. D. Respiratory rate. E. Deep tendon reflexes. F. Gastrointestinal assessment findings.

Correct Answer is ["A","B","E"]

Explanation

The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.

Choice A rationale:

Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.

Choice B rationale:

Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.

Choice C rationale:

The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.

Choice D rationale:

The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.

Choice E rationale:

Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.

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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?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is B

Explanation

Correct Answer is ["A","B","E"]

Explanation

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