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    Hesi rn n404 maternity and pediatrics proctored exam

    The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding. occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?

    Explanation & Rationale

    Rationale: A. Mild nausea and anorexia: Mild nausea and loss of appetite are common postoperative findings and are typically self-limiting. While these symptoms should be monitored, they do not pose an immediate threat to the client’s safety. B. Uterine atony: Uterine atony occurs when the uterus fails to contract effectively after delivery, leading to significant postpartum hemorrhage. This is a life-threatening complication requiring immediate intervention, including uterine massage and administration of uterotonic medications to prevent hypovolemic shock. C. Respiratory rate of 12 breaths/minute: A respiratory rate of 12 breaths per minute is within the lower end of the normal adult range. While respiratory status should be monitored after general anesthesia, this finding alone does not indicate critical compromise. D. Positive test for deep vein thrombosis: A positive DVT test is serious and requires treatment to prevent complications such as pulmonary embolism. However, it does not pose the same immediate, life-threatening risk as uncontrolled postpartum bleeding from uterine atony.

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