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A nurse is caring for a client in the fourth stage of labor after a vaginal delivery.

History and Physical:

BP: 144/92 mmHg.

Pulse: 99 bpm.
Respirations: 17/min.

Pulse Ox: 97%.

Temperature: 100.4 F (38.0 C).

Pain score: 1/10.

The nurse should first address the client's ____________ (assessment finding), followed by the client's ____________ (assessment finding).

A.

Blood pressure.

B.

Pulse.

C.

Respirations.

D.

Temperature.

E.

Temperature.

Answer and Explanation

The Correct Answer is A

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.


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.

Choice B rationale

Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.

Choice C rationale

Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.

Choice D rationale

Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.

Correct Answer is C

Explanation

Choice A rationale

Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.

Choice B rationale

Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.

Choice C rationale

Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.

Choice D rationale

There is no Category 4 in fetal heart rate monitoring.

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