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 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