Question

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?

A. Place the client on seizure precautions.
Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Placing the client on seizure precautions is not an appropriate action.
B. Notify the charge nurse.
Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Notifying the charge nurse of the finding is not an appropriate response.
C. Cover the client with warm blankets.
Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. The nurse should cover the client with a warm blanket following delivery.
D. Determine the client's temperature.
Rationale: Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. Determining the client's temperature is not an appropriate action.

Answer 1

The appropriate action for a nurse when a patient experiences shaking chills postpartum is to cover them with warm blankets to provide comfort and warmth. Seizure precautions and notifying the charge nurse are not immediate actions for common postpartum chills. Temperature should be monitored if chills persist.

Step-by-step explanation:

When a client is experiencing shaking chills in the immediate postpartum period, it is generally caused by a few physiological responses, namely changes in room temperature, hormonal shifts particularly increased production of epinephrine during labor, and the relief of pressure on pelvic nerves after delivery. The appropriate nursing action to take in this case would be to provide comfort by warming the patient. Therefore, covering the client with warm blankets is the best intervention to manage postpartum shaking chills. While shaking chills could be a concern in some medical cases, it is a common occurrence after childbirth that does not typically require seizure precautions or immediate notification of the charge nurse, although keeping an eye on the overall condition of the client is essential. Also, determining the client's temperature may be necessary if warmth does not alleviate the chills or if there's a concern for infection, but it is not the first action to be taken for shaking chills with no other symptoms.