An unlicensed assistive personnel (UAP) informs the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is experiencing a severe headache.
The client’s blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client’s fundus is firm and one fingerbreadth above the umbilicus.
What should the charge nurse do first?
Notify the healthcare provider of the assessment findings.
Obtain a STAT hemoglobin and hematocrit.
Determine if the client received anesthesia during delivery.
Assign a practical nurse (PN) to reassess the client’s vital signs.
The Correct Answer is C
Choice A rationale
While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.
Choice B rationale
Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.
Choice C rationale
Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.
Choice D rationale
Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.
Choice B rationale
Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.
Choice C rationale
Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.
Choice D rationale
Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.
Correct Answer is D
Explanation
Choice A rationale
While episodes of headache and irritability can occur as side effects of metformin and menotropins, they are not typically severe enough to warrant immediate reporting.
Choice B rationale
Persistent daytime fatigue can be a side effect of these medications, but it is also a common symptom in pregnancy and is not typically a cause for immediate concern.
Choice C rationale
Nausea and vomiting can occur as side effects of these medications. However, they are common side effects and are not typically a cause for immediate concern unless they are severe or persistent.
Choice D rationale
A rapid increase in abdominal girth can be a sign of ovarian hyperstimulation syndrome, a rare but potentially serious side effect of fertility treatments. This condition can cause rapid weight gain, abdominal pain, and bloating, and should be reported immediately.
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