The nurse is providing care in PACU for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health care provider?

Correct Answer: A

Rationale: The correct answer is A: Pulmonary embolism. The patient's symptoms of chest tightness, tachypnea, hypotension, and decreasing oxygen saturation levels are indicative of a potential pulmonary embolism, which is a serious complication post-cesarean section. A pulmonary embolism occurs when a blood clot travels to the lungs, causing respiratory distress and cardiovascular compromise. The nurse should report this immediately to the healthcare provider for prompt intervention to prevent further complications. Incorrect choices: B: Postpartum hemorrhage - Symptoms of postpartum hemorrhage include excessive bleeding, not chest tightness and respiratory distress. C: Surgical-site infection - Symptoms of surgical-site infection include redness, swelling, and drainage at the incision site, not chest tightness and respiratory distress. D: Developing endometritis - Symptoms of endometritis include fever, pelvic pain, and abnormal vaginal discharge, not chest tightness and respiratory distress.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct: 1. The deceleration pattern described, beginning near the acme of the contraction and extending beyond, is associated with uteroplacental insufficiency. 2. Uteroplacental insufficiency indicates a potential problem with oxygen and nutrient delivery to the fetus. 3. This situation requires immediate intervention to improve oxygenation to the fetus. 4. Monitoring alone is not sufficient; action is needed to address the underlying issue. 5. Therefore, the correct nursing action in this situation is to recognize the potential uteroplacental insufficiency and take appropriate measures to address it. Summary of why other choices are incorrect: A: This pattern reflects variable decelerations - Incorrect because the described pattern is not characteristic of variable decelerations. B: Document this Category I fetal heart rate pattern and decrease the rate of the - Incorrect because immediate action is needed in the presence of potential uteroplacental insufficiency.

Correct Answer: B

Rationale: The correct answer is B: Continuous electronic fetal monitoring. This method is most appropriate for a woman with a history of hypertension during pregnancy because it allows continuous monitoring of fetal heart rate patterns and uterine contractions, providing real-time data to detect any signs of fetal distress promptly. Continuous monitoring is crucial in high-risk pregnancies to ensure timely intervention if any issues arise. A: Continuous auscultation with a fetoscope is not ideal for a woman with a history of hypertension as it does not provide continuous monitoring and may miss subtle changes in fetal well-being. C: Intermittent assessment with a Doppler transducer does not offer continuous monitoring, which is essential in high-risk pregnancies like hypertension. D: Intermittent electronic fetal monitoring for 15 minutes each hour is not as effective as continuous monitoring in detecting changes in fetal well-being promptly, which is crucial in cases of hypertension during pregnancy.

Correct Answer: C

Rationale: Rationale for correct answer (C): Recording the normal pattern is indicated because the deceleration pattern mirroring uterine contractions is a reassuring sign of fetal well-being. It indicates a physiologic response to labor. Repositioning the patient (A) is unnecessary as the pattern is normal. Applying a fetal scalp electrode (B) is invasive and unnecessary in this scenario. Administering oxygen (D) is not indicated as the fetal heart rate pattern is normal.

Correct Answer: B

Rationale: The correct answer is B because it aligns with the nurse's responsibility to educate and provide information to the patient and their support person. Teaching about the monitoring equipment and addressing any questions ensures that the patient and their support person are informed and empowered. This promotes patient understanding and involvement in their care, leading to better outcomes. Choice A is incorrect because the nurse should initiate corrective actions promptly for abnormal findings without waiting for physician input. Choice C is incorrect as it focuses solely on documentation rather than patient education. Choice D is incorrect as it neglects the importance of involving the support person in the care process.