OB nursing PE(pulmonary Emobolism) question

[truckinusa, BSN, LPN, RN]

Here is the question:

15. Misty, a postpartum woman, has a deep vein thrombosis. She is now 48 hours postpartum and states, I feel anxious and have some pain in my chest”. Misty's respiratory rate is 28 breaths/minute. The perinatal nurse's most appropriate first step would be to:

A) Summon help

B) Initiate oxygen therapy

C) Assess Misty's blood pressure and pulse

D) Assist Misty into a Trendelenberg position

Why is the answer A or B? Google tells me the answer is A, teacher says B. I'm just trying to understand. I answered A because you call a code first. Overall I think it is a crappy question, but maybe I am missing something. Yes, I know the ABC priority.

[AJJKRN]

What do you think and why...remember what is happening pathophysiologically to the lungs and the patients ability to exchange oxygen and carbon dioxide, the tissues/vessels involved, and not to mention the anxiety that having shortness of breath can cause...

[truckinusa, BSN, LPN, RN]

Isn't oxygen a comfort measure at this point since they are experiencing a PE? I guess what I am asking is if there is any rationale for summoning help first?

[AJJKRN]

Isn't oxygen a comfort measure at this point since they are experiencing a PE? I guess what I am asking is if there is any rationale for summoning help first?

Depends on what the patients O2 sat is, if there's a blood clot blocking enough blood flow to the lungs, then no, O2 is not just for comfort. In other words, just how blue is your patient? Wait til you see someone suddenly develop a large PE, think about what your book says are the classic signs and symptoms. (Look up saddle PE's...yikes) Deceased O2 should be one of them. I bet you will take the few seconds to slap on O2 before calling for help because in NCLEX world, you have all the supplies readily available right? In a real life situation, unless the patient becomes really unstable, you will be the one performing interventions based on your nursing judgement, gathering data, and then calling the RT and the MD for back up, and possibly other nursing staff members. You'd be surprised just how fast you will be able to do all of these things with experience! Besides, this is a NCLEX style question, set in a perfect NCLEX style world, that doesn't take into account that humans multi-task! There is a rationale to calling for help but the way I understand NCLEX world, the best choice is usually the one showing what intervention that the primary nurse performs first (like the answer will almost never be to call the MD). Helpful?

[LoriRNCM, ADN, ASN, RN]

Think perfusion. Always priority.

[Esme12, ASN, BSN, RN]

Isn't oxygen a comfort measure at this point since they are experiencing a PE? I guess what I am asking is if there is any rationale for summoning help first?

In the real world...your patient isn't looking very good.....they are SOB complaining of chest pain what would your first response be thinking ABC.....

Airway: yup she is moving air but she doesn't look good

Breathing: Yup she is breathing but way to fast

Circulation: Yup she has a pulse but it is fast and her O2 sat is low

What is the FIRST thing I should do as the NURSE.

Apply some oxygen and call for help. IN this case she has an actual physical reason for hypoxia, the pulmonary emboli, so no the O2 is a treatment for hypoxia and not just a "comfort measure"