A client who is a gravida 1, para 0, is transferred to the recovery room following a normal vaginal delivery of a healthy newborn. The practical nurse (PN) observes that the client is shaking uncontrollably and states she is cold. Which intervention should the PN perform?
Take her temperature and assess for additional signs of infection.
Elevate her legs in a shock position and apply external heat.
Apply light, warmed blankets and assure her that this is normal following delivery.
Encourage the client to turn to her left side and administer oxygen by face mask.
The Correct Answer is C
A. Take her temperature and assess for additional signs of infection: While monitoring for infection is important postpartum, immediate uncontrollable shaking and feeling cold in a healthy client is usually a normal physiologic response rather than a sign of infection.
B. Elevate her legs in a shock position and apply external heat: Placing the client in a shock position is unnecessary unless there are signs of hypotension or poor perfusion. Uncontrolled shaking and feeling cold alone do not indicate shock.
C. Apply light, warmed blankets and assure her that this is normal following delivery: Postpartum chills are common and result from rapid hormonal and fluid shifts after delivery. Applying warmed blankets and providing reassurance helps the client feel more comfortable and addresses the normal physiologic response.
D. Encourage the client to turn to her left side and administer oxygen by face mask: Turning to the left side and giving oxygen is indicated for compromised circulation or respiratory distress. In a stable postpartum client experiencing normal chills, these interventions are unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The contraction pattern described is mild, irregular, and spaced more than 5 minutes apart, which is consistent with early or false labor. Hospital admission is not indicated until active labor begins, characterized by stronger, regular contractions.
B. Encouraging hydration is helpful but insufficient in guiding labor management. While dehydration can contribute to irregular contractions, the main focus should be on recognizing the signs of true labor and when to seek care.
C. True labor is indicated when contractions become regular, stronger, and closer together typically every 5 minutes for one hour signaling the onset of active labor that requires hospital evaluation.
D. Although urinary tract infections can cause uterine irritability, the contractions described are consistent with early labor, not infection. Without symptoms such as dysuria or frequency, immediate hospital evaluation for UTI is unnecessary.
Correct Answer is A
Explanation
A. Gravida 2, Para 1: Gravida refers to the total number of pregnancies a client has had, including the current one, so this client is gravida 2. Para refers to the number of pregnancies carried to viability (≥20 weeks), so having one previous child makes her para 1.
B. Gravida 2, Para 0: While the client is correctly identified as gravida 2, she has previously carried a pregnancy to viability, so para 0 is inaccurate.
C. Gravida 1, Para 1: Gravida 1 would indicate this is the client’s first pregnancy, which is inconsistent with her history of one prior child.
D. Gravida 1, Para 0: Both the gravida and para are incorrect because this is her second pregnancy and she has delivered one child previously.
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