A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have some pain in my chest." The patient's respiratory rate is 28 breaths per minute. After calling for help, which action by the perinatal nurse takes priority?
A.
Administer oxygen.
B.
Document the findings.
C.
Take a full set of vital signs.
D.
Prepare to give pain medication.
ANS: A
The presence of dyspnea and tachypnea may signal pulmonary embolism, and the nurse should summon help immediately to deal with this condition. After that, administer oxygen, raise the head of the bed, assess vital signs, or begin CPR immediately if needed. Documentation is only correct as the priority action when the findings are normal. Pain medication is a lower priority.
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