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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Correct Answer is A
Explanation
Choice A rationale
Methylergonovine (Methergine) is contraindicated in clients with hypertension because it can cause severe hypertension by increasing vascular resistance, leading to potential complications such as stroke.
Choice B rationale
Oxytocin (Pitocin) is used to induce labor and control postpartum hemorrhage and does not significantly increase blood pressure, making it safe for use in hypertensive patients.
Choice C rationale
Carboprost (Hemabate) is used to control severe postpartum hemorrhage and does not have significant effects on blood pressure. It is generally safe for hypertensive patients.
Choice D rationale
Misoprostol (Cytotec) is used for postpartum hemorrhage management and does not significantly affect blood pressure, making it safe for hypertensive patients.
Correct Answer is D
Explanation
Choice A rationale
Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
Choice B rationale
Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.
Choice C rationale
Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.
Choice D rationale
Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .