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?
Explanation & Rationale
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.