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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 C

Explanation

Choice A rationale

Male condoms are effective in preventing pregnancy and sexually transmitted infections, but their reliability can be compromised by improper use or breakage.

Choice B rationale

Vaginal rings provide hormonal contraception and are effective, but they may be less reliable compared to implants due to potential for incorrect use.

Choice C rationale

Hormonal implants are highly reliable because they provide continuous contraception over an extended period (up to 3-5 years) with minimal user intervention.

Choice D rationale

Oral contraceptives are effective when taken correctly, but their reliability can be reduced by missed doses or incorrect use.

Correct Answer is C

Explanation

Choice A rationale

A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.

Choice B rationale

A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.

Choice C rationale

Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.

Choice D rationale

A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.

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