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. .

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

Decreased deep tendon reflexes are not typically associated with preeclampsia. In fact, hyperreflexia or increased deep tendon reflexes might be observed due to central nervous system irritability in preeclampsia.

Choice B rationale

Uterine contractions are related to labor and not a specific indicator of preeclampsia. While they might occur simultaneously, they are not diagnostic of preeclampsia.

Choice C rationale

Proteinuria, the presence of excess protein in the urine, is a key diagnostic criterion for preeclampsia. It indicates kidney involvement and is used along with elevated blood pressure to diagnose this condition.

Choice D rationale

Increased blood glucose levels are associated with gestational diabetes rather than preeclampsia. Elevated blood pressure and proteinuria are the hallmarks of preeclampsia.

A. Blood pressure. B. Pulse. C. Respirations. D. Temperature.

Correct Answer is A

Explanation

Choice A rationale

Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.

Choice B rationale

Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.

Choice C rationale

Respirations are within normal range (17/min) and do not require immediate intervention.

Choice D rationale

Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.

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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?

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Naxlex Comprehensive Predictor Exams

A 38-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks gestation.Assessment findings include: blood pressure 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min.The nurse suspects preeclampsia.What additional finding would the nurse assess for?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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