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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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Correct Answer is D

Explanation

Choice A rationale

Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.

Choice B rationale

Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.

Choice C rationale

Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.

Choice D rationale

Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .

Correct Answer is A

Explanation

Choice A rationale

Pelvic pain and fatigue can be indicators of endometritis, an infection of the uterine lining. It often manifests with pain, fever, and general malaise, and requires further evaluation and intervention.

Choice B rationale

Light amount of dark red lochia with a bloody odor is a normal postpartum finding. Lochia progresses through different stages, and dark red lochia, which occurs in the later stages, typically has a bloody odor.

Choice C rationale

Hematuria, or the presence of blood in the urine, is not a typical symptom of endometritis. It may indicate a urinary tract infection or other renal issues instead.

Choice D rationale

A localized area of breast tenderness may indicate mastitis, an infection of the breast tissue. It is not related to endometritis but requires attention and treatment.

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