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
Placenta formation begins shortly after implantation, but it continues to develop throughout the first trimester and into the early second trimester, making it less precise to attribute the
first 8 weeks solely to this process.
Choice B rationale
Fertilization occurs within the first week after ovulation, marking the beginning of pregnancy, but it is a singular event that happens prior to the developmental processes vulnerable to teratogens.
Choice C rationale
Organogenesis is the critical period during which the major organs and structures of the fetus form, typically occurring between the third and eighth weeks of gestation. This is the
time when the fetus is most susceptible to the effects of teratogens, which can cause congenital anomalies.
Choice D rationale
Implantation occurs approximately 6-10 days after fertilization, embedding the blastocyst into the uterine lining. While crucial, it is not the primary period when teratogenic effects are
most significant, as this happens during organogenesis.
Correct Answer is C
Explanation
Choice A rationale
Dexamethasone is a corticosteroid and is not used for treating ectopic pregnancy.
Choice B rationale
Clomid (clomiphene citrate) is used to stimulate ovulation, not to treat ectopic pregnancy.
Choice C rationale
Methotrexate is a chemotherapeutic agent that effectively stops the growth of ectopic pregnancy cells, allowing the pregnancy tissue to be reabsorbed by the body.
Choice D rationale
Progesterone supports pregnancy and is not used to treat ectopic pregnancy.