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 D
Explanation
Choice A rationale
Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to
ectopic pregnancy.
Choice B rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.
Choice C rationale
Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside
the uterus.
Choice D rationale
Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing
localized pain.
Correct Answer is A
Explanation
Step 1 is: October 17 + 7 days = October 24.
Step 2 is: October 24 - 3 months = July 24.
Step 3 is: July 24 + 1 year = July 24. Answer: July 24 (0724)