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).
Blood pressure.
Pulse.
Respirations.
Temperature.
Temperature.
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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Correct Answer is D
Explanation
Choice A rationale
Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.
Choice B rationale
Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not
mucus accumulation.
Choice C rationale
Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are
extremely high.
Choice D rationale
Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps
reduce the chances of bilirubin buildup.
Correct Answer is C
Explanation
Choice A rationale
A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.
Choice B rationale
When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.
Choice C rationale
Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.
Choice D rationale
Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.