Which patient requires immediate intervention by the labor and delivery nurse?
1. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg
2. Primip that delivered one hour ago with WBC of 50,000
3. Multip at 5 cm with a respiratory rate of 22 between contractions
4. Primip in active labor with urine output of 100 ml/hour
Correct Answer: 2
Rationale 1: 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.
Rationale 2: A white count of 25,000–30,000 is normal at the end of labor and during the early postpartum period. This white count is abnormally high and requires further assessment and provider notification.
Rationale 3: The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This patient requires no further intervention.
Rationale 4: This is a normal urine output and requires no further intervention.
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