The nurse is assisting a newly delivered mother in ambulating to ...

[Chloeellawright]

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action?
 
  1. Ensure the client's modesty as she falls.
  2. Be certain the client does not hit the head on anything.
  3. Call for immediate assistance.
  4. Check the vital signs and for excessive vaginal bleeding.

Question 2

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face?
 
  1. Toward the nearest corner of the head of the bed
  2. Toward the side of the bed
  3. Toward the far corner of the foot of the bed
  4. Directly toward the client

[Heffejeff]

Answer to Question 1

Correct Answer: 2
Rationale 1: This is not the priority for the nurse at this time.
Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor.
Rationale 3: This is important; however, it does not address that the client is falling.
Rationale 4: This is important to do after the client has been assisted to the floor.

Answer to Question 2

Correct Answer: 3
Rationale 1: This position could cause the nurse's trunk to twist.
Rationale 2: This position could cause the nurse's trunk to twist.
Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.
Rationale 4: This position could cause the nurse's trunk to twist.