NursingPlex
    Sign In
    ATI Maternity proctored quiz

    A nurse is assessing a client who is 12 hours postpartum and received spinal anesthesia for a cesarean birth.Which of the following findings requires immediate intervention by the nurse?

    Explanation & Rationale

    Choice A rationaleA urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.Choice B rationaleHeadache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.Choice C rationaleA blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.Choice D rationaleA respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.

    🔒 Submit your answer to reveal