Which client requires immediate intervention by the labor and ...

[gonzo233]

Which client requires immediate intervention by the labor and delivery nurse?
 
  1. Primipara in active labor with urine output of 100 mL/hour
  2. Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000
  3. Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg
  4. Multipara at 5 cm with a respiratory rate of 22 between contractions

Question 2

A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. How should the nurse interpret this complaint?
 
  1. The client's complaint is congruent with her current stage of labor.
  2. The client's complaint may indicate the need for delivery via cesarean section.
  3. Based upon the client's complaint, she is experiencing the active phase of labor.
  4. The client's complaint is consistent with placental separation, which is normal for her current stage of labor.

[Pariscourtney]

Answer to Question 1

2
Explanation:
1. This is a normal urine output and requires no further intervention.
2. A white count of 25,000 to 30,000 is normal at the end of labor and during the early postpartum period. This WBC count is abnormally high and requires further assessment and provider notification.
3. The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor.
4. The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This client requires no further intervention.

Answer to Question 2

1
Explanation:
1. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
2. The objective findings and client's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
3. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
4. Placental separation occurs after the infant is born.