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. .
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
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.