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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 B

Explanation

Choice A rationale

Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.

Choice B rationale

Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.

Choice C rationale

Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.

Choice D rationale

Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.

Correct Answer is A

Explanation

Choice A rationale

Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine

muscle tone and increased risk of postpartum hemorrhage.

Choice B rationale

Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.

Choice C rationale

Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.

Choice D rationale

Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.

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