2024 PN NCLEX Questions Nursing Practice Question
A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take?
Correct Answer: C
Rationale: An increased pulse rate from 70 to 100 beats per minute in a client in the fourth stage of labor may indicate potential complications such as hemorrhage or other cardiovascular issues. Checking the client's uterine fundus is crucial to assess for uterine atony, a common cause of increased pulse and possible blood loss.
Continuing to check vital signs (Option A) does not address the immediate concern of potential hemorrhage. Notifying the registered nurse (Option B) is important but should follow an assessment of the fundus. Documenting vital signs (Option D) is necessary but not a priority in this situation. Immediate assessment of the uterine fundus is essential for timely intervention.