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 C
Explanation
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.
Correct Answer is B
Explanation
Choice A rationale
Open heart surgery is unrelated to the development of vaginal fistulas.
Choice B rationale
Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.
Choice C rationale
Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.
Choice D rationale
Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.