The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding. occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?

Mild nausea and anorexia.

Uterine atony.

Respiratory rate of 12 breaths/minute.

positive test for deep vein thrombosis.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Mild nausea and anorexia: Mild nausea and loss of appetite are common postoperative findings and are typically self-limiting. While these symptoms should be monitored, they do not pose an immediate threat to the client’s safety.

B. Uterine atony: Uterine atony occurs when the uterus fails to contract effectively after delivery, leading to significant postpartum hemorrhage. This is a life-threatening complication requiring immediate intervention, including uterine massage and administration of uterotonic medications to prevent hypovolemic shock.

C. Respiratory rate of 12 breaths/minute: A respiratory rate of 12 breaths per minute is within the lower end of the normal adult range. While respiratory status should be monitored after general anesthesia, this finding alone does not indicate critical compromise.

D. Positive test for deep vein thrombosis: A positive DVT test is serious and requires treatment to prevent complications such as pulmonary embolism. However, it does not pose the same immediate, life-threatening risk as uncontrolled postpartum bleeding from uterine atony.

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Correct Answer is C

Explanation

Rationale:

A. Shallow and irregular respirations: Shallow and irregular respirations are often normal in newborns, especially during sleep or periods of rest. These patterns alone do not indicate respiratory distress unless accompanied by other signs such as retractions or cyanosis.

B. Abdominal breathing with synchronous chest movement: Normal newborns primarily use diaphragmatic (abdominal) breathing with coordinated chest movement. This is expected and does not signify respiratory distress.

C. Flaring of the nares: Flaring of the nares occurs when the newborn is attempting to increase airflow due to difficulty breathing. It is a classic early sign of respiratory distress and indicates that the infant is using accessory muscles to breathe, requiring prompt evaluation.

D. Respiratory rate of 50 breaths/minute: A respiratory rate of 50 breaths per minute is within the normal newborn range of 30–60 breaths per minute. While it should be monitored, this rate alone does not indicate respiratory distress.

A. Document the finding in the infant's record. B. Teach the parents about congenital heart defects C. Apply oxygen per nasal cannula at 3 L/min. D. Notify the pediatrician immediately.

Correct Answer is D

Explanation

Rationale:

A. Document the finding in the infant's record: Documentation is necessary for all assessment findings, but an irregular heart rate in a newborn may indicate a potentially serious cardiac issue. Simply recording it without notifying the healthcare provider could delay critical evaluation or intervention.

B. Teach the parents about congenital heart defects: Parental education is important, but it is not the immediate priority when a newborn has an irregular heart rate. Immediate assessment and guidance from a healthcare provider take precedence over education.

C. Apply oxygen per nasal cannula at 3 L/min: Administering oxygen is only indicated if the infant shows signs of hypoxia or respiratory distress. An irregular heart rate alone does not automatically require supplemental oxygen without further assessment.

D. Notify the pediatrician immediately: Immediate notification of the pediatrician is essential because an irregular heart rate may signal arrhythmias, congenital heart defects, or other serious cardiac conditions. Prompt evaluation ensures timely intervention to prevent complications.

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The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding. occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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