During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate?
A)This is evidence of incomplete expulsion of the placenta.
B)The client has a full bladder.
C)This is a normal reaction to the ending of the physical exertion of labor.
D)The client has a fever from a postpartum infection.

Question

Quizplus · Accepted Answer

A)Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
B)Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
C)Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
D)Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.

During an Assessment, the Nurse Notes the Client in the Fourth