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?

Question

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.

Answer 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.