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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

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.

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.

Choice B rationale

The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.

Choice C rationale

Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.

Choice D rationale

While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.

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