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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?

A.

Respiratory rate 10/min.

B.

Blood pressure 100/70 mm Hg.

C.

Urinary output 30 ml/hr.

D.

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Betamethasone is a corticosteroid that accelerates fetal lung maturity by increasing the production of surfactant, which reduces respiratory distress syndrome in preterm infants.

Choice B rationale

While betamethasone can cause transient increases in fetal heart rate, its primary purpose is not to increase fetal heart rate. Its role is in enhancing lung maturity.

Choice C rationale

Betamethasone does not directly increase amniotic fluid levels. Its main function is in the maturation of fetal lungs.

Choice D rationale

Betamethasone is not used to stop preterm labor contractions. It is used to accelerate fetal lung development in preterm labor cases.

Correct Answer is ["A","B","C","D","E","F"]

Explanation

B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.

D. Maintain an eye mask over the newborn's eyes.

E. Reposition the newborn every 2 hours.

F. Report sunken fontanels to the provider. Contraindicated:

A. Apply lotion to the skin every 4 hours.

C. Newborn feedings should be every 8 hours.

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