A nurse is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth.Which of the following findings requires immediate intervention by the nurse?
Respiratory rate 10/min.
Blood pressure 100/70 mm Hg.
Urinary output 30 ml/hr.
Headache pain rated a 6 on a scale of 0 to 10. .
The Correct Answer is A
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate life-threatening condition. .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.
Correct Answer is C
Explanation
Choice A rationale
Placenta formation begins shortly after implantation, but it continues to develop throughout the first trimester and into the early second trimester, making it less precise to attribute the first 8 weeks solely to this process.
Choice B rationale
Fertilization occurs within the first week after ovulation, marking the beginning of pregnancy, but it is a singular event that happens prior to the developmental processes vulnerable to teratogens.
Choice C rationale
Organogenesis is the critical period during which the major organs and structures of the fetus form, typically occurring between the third and eighth weeks of gestation. This is the time when the fetus is most susceptible to the effects of teratogens, which can cause congenital anomalies.
Choice D rationale
Implantation occurs approximately 6-10 days after fertilization, embedding the blastocyst into the uterine lining. While crucial, it is not the primary period when teratogenic effects are most significant, as this happens during organogenesis.
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