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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 B

Explanation

Choice A rationale

Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery,

which is more often related to other factors like fetal distress or failure to progress.

Choice B rationale

Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding

after birth.

Choice C rationale

In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and

trauma.

Choice D rationale

Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and

hemorrhage, not infection.

Correct Answer is A

Explanation

Step 1 is: 12 mg ÷ 6 mg/ml.

Step 2 is: 12 ÷ 6 = 2 ml. Answer: 2 ml

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