A nurse is caring for a 28-year-old female client in the fourth stage of labor after a vaginal delivery in the labor and delivery unit.
History and Physical: The client is a Gravida 3 Para 2 (T2P0A0L2) with chronic hypertension. She was admitted for medical induction of labor due to gestational diabetes with a Bishop score of 9 on admission. The plan was to induce labor with oxytocin.
Vital Signs:
1130:
- Blood Pressure: 144/92 mmHg
- Pulse: 99 bpm
- Respirations: 17/min
- Temperature: 100.4°F (38.0°C)
- Pulse Ox: 97%
Nurses Notes: At 1040, the client underwent a vacuum-assisted vaginal delivery of a viable female infant weighing 4215 grams. The placenta was manually extracted at 1035, appearing intact. At 1130, the fundus was boggy, midline, and at the umbilicus. Lochia rubra was heavy with small clots noted. The IV was patent and currently infusing ordered oxytocin.
Diagnostic Tests:
- Hemoglobin: 11g/dL (9.5-11 g/dL)
- Hematocrit: 33% (28-33%)
- White Blood Cell Count: 12,000/mm³ (5,600-17,000/mm³)
- Platelets: 151,000/mm³ (140,000-400,000/mm³)
- Protein Creatinine Ratio: 0.01 (less than 0.3)
- HbA1c: 8.9% (less than 5.7%)
Querry: Which of the following assessment findings require follow-up? Select All That Apply.
Temperature
Fundal tone
Lochia
Respiratory rate
White blood cell count
Blood pressure
Correct Answer : A,B,C,F
Choice A rationale:
A postpartum temperature of 100.4°F (38.0°C) or higher may indicate an infection. Infections can occur after delivery, particularly if there was a manual extraction of the placenta, as in
this case. Close monitoring and further assessment are necessary to ensure the client does not develop sepsis or other complications.
Choice B rationale:
Fundal tone should be firm and well-contracted to prevent excessive bleeding postpartum. A boggy, midline fundus suggests that the uterus is not contracting effectively, increasing the
risk for postpartum hemorrhage. This requires immediate attention and intervention to ensure adequate uterine tone and control bleeding.
Choice C rationale:
Lochia should be monitored for quantity, color, and the presence of clots. Heavy lochia with small clots indicates that the client may be experiencing postpartum hemorrhage, which is a
significant concern. This can be related to uterine atony, retained placental fragments, or coagulopathies and warrants prompt evaluation and intervention.
Choice D rationale:
A respiratory rate of 17/min is within the normal adult range (12-20/min) and does not require follow-up. There are no signs of respiratory distress or abnormalities in this case, indicating
that the client's respiratory status is stable and does not necessitate further evaluation.
Choice E rationale:
A white blood cell count of 12,000/mm³ is within the expected range for postpartum women, where normal values can be elevated due to physiological stress and inflammation from
delivery. This level does not indicate infection or pathology and does not require follow-up in the context provided.
Choice F rationale:
Blood pressure of 144/92 mmHg is elevated and concerning, particularly in a postpartum client with a history of chronic hypertension and gestational diabetes. This could signal
postpartum preeclampsia or other hypertensive disorders, requiring careful monitoring and management to prevent complications like seizures, stroke, or organ damage.
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View Related questions
Correct Answer is ["A","B","C"]
Explanation
Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.
Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.
Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.
Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.
Choice C: Position the client in a lateral position.
Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.
Correct Answer is A
Explanation
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. .