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 C

Explanation

The correct answer is choice C. Assist the client to breathe into a paper bag.

Choice A rationale:

Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.

Choice B rationale:

Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.

Choice C rationale:

Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.

Choice D rationale:

Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.

A. Vitamin K decreases the newborn's risk of jaundice. B. Vitamin K decreases the newborn's risk of health care-associated infections. C. Vitamin K decreases the newborn's risk of hemorrhagic disorders. D. Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine.

Correct Answer is C

Explanation

Choice A rationale :

Vitamin K decreases the newborn's risk of jaundice. Rationale: This statement is incorrect. Vitamin K plays no direct role in reducing the risk of jaundice in newborns. Jaundice is primarily caused by the accumulation of bilirubin in the blood, which is a different issue than hemorrhagic disorders.

Choice B rationale

Vitamin K decreases the newborn's risk of healthcare-associated infections. Rationale: This statement is incorrect. Vitamin K is not related to reducing the risk of healthcare-associated infections. Its main function is related to blood clotting and preventing hemorrhagic disorders.

Choice C rationale

Vitamin K decreases the newborn's risk of hemorrhagic disorders. Rationale: This statement is correct. Vitamin K is essential for the production of clotting factors in the blood, which helps prevent bleeding or hemorrhagic disorders in newborns. Newborns are born with low levels of vitamin K, so administering a vitamin K injection at birth is a common practice to prevent potential bleeding issues.

Choice D rationale

Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine. Rationale: This statement is incorrect. Vitamin K is not directly related to reducing the risk of complications from the Hepatitis B vaccine. The vaccine is designed to protect against Hepatitis B infection, and vitamin K is not involved in its efficacy or safety.

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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

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Explanation

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Correct Answer is C

Explanation

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