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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 ["A","B","C","D","G"]

Explanation

Choice A: Respiratory assessment

The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.

Choice B: Hemoglobin

The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.

Choice C: Serum glucose

The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.

Choice D: Heart rate

The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.

Choice G: Hematocrit

The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2

Correct Answer is C

Explanation

Choice A rationale

Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage

heavy bleeding postpartum.

Choice B rationale

Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to

addressing the immediate bleeding.

Choice C rationale

Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum

hemorrhage, and fundal massage is the first intervention to manage it.

Choice D rationale

Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through

fundal massage.

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