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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","B","C","D","E"]

Explanation

Choice A rationale

Postpartum blues typically resolve within the first two weeks postpartum and involve mild symptoms like mood swings and irritability. In contrast, postpartum depression can persist

longer and requires treatment.

Choice B rationale

Symptoms of postpartum blues usually disappear without medical intervention, whereas postpartum depression often needs professional treatment to manage the more severe and

persistent symptoms.

Choice C rationale

Postpartum depression can impair a mother's ability to care for herself and her baby safely, requiring intervention to prevent harm. Postpartum blues do not typically cause such severe

functional impairment.

Choice D rationale

Postpartum depression may require antidepressants for treatment due to its severity. Postpartum blues generally do not necessitate such interventions and are managed through

support and reassurance.

Choice E rationale

Postpartum depression can occur at any time within the first 12 months after delivery, while postpartum blues are usually confined to the initial two weeks postpartum.

Correct Answer is D

Explanation

Choice A rationale

Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.

Choice B rationale

Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.

Choice C rationale

Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.

Choice D rationale

A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .

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