A nurse is performing an assessment of a client who is scheduled for a caesarean delivery. Which assessment finding would indicate a need to contact the physician?

Appeared in: DHS 2018 shift 1st

Explanation

The normal fetal heart rate (FHR) range is 110 to 160 beats per minute.
An FHR of 180 beats/min is defined as fetal tachycardia.
Fetal tachycardia is a non-reassuring sign that can indicate fetal hypoxia, maternal fever, infection, or dehydration.
Given that the client is scheduled for a caesarean section, any sign of fetal compromise warrants immediate communication with the physician to ensure the safety of the fetus.

Option A: A haemoglobin level of 11 g/dL is at the lower end of the normal range for a pregnant woman, especially in the third trimester, due to physiological hemodilution. It is not an acute finding that requires immediate physician notification.
Option C: A maternal pulse rate of 85 beats/min is within the normal range for an adult (60-100 beats/min).
Option D: A white blood cell (WBC) count of 12,000/mm³ is a normal finding during pregnancy. Physiological leukocytosis (WBC counts up to 15,000/mm³) is common.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of abnormal assessment findings in a pregnant client requiring physician notification to guide bedside assessment, documentation, and the next nursing action.
Recognizing and reporting a non-reassuring fetal heart rate is a critical nursing responsibility to prevent adverse fetal outcomes like hypoxic injury or death.
Nurses must be able to differentiate between normal physiological changes of pregnancy (like hemodilution and leukocytosis) and pathological signs requiring urgent intervention.
What if? If the fetal heart rate was 150 beats/min with moderate variability, this would be a normal, reassuring finding, and the nurse would continue routine monitoring without needing to contact the physician.

How to Approach the Question

First, read the question carefully to understand the clinical scenario: a pre-caesarean assessment.
Identify the core task: determine which finding is abnormal and requires physician notification.
Review each option and compare the given value to the established normal physiological ranges for a pregnant client.
Option A (Hb 11): Recall that Hb drops slightly in pregnancy. 11 g/dL is borderline but acceptable.
Option B (FHR 180): Recall the normal FHR is 110-160 bpm. 180 bpm is clearly outside this range (tachycardia).
Option C (Maternal Pulse 85): This is within the normal adult range of 60-100 bpm.

Concept Tested & Keywords

Concept Tested: Identification of abnormal assessment findings in a pregnant client requiring physician notification.
Stem keywords: assessment, caesarean delivery, contact the physician
Lead-in keywords: indicate a need
Clinical cues: The client is scheduled for a caesarean delivery, which increases the urgency of addressing any signs of fetal distress.

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E6 Parks TextBook of Preventive & Social Medicine part 2 — Subpart A (pp 1-232 of 464) p. 18-20

E6 Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Part 2 — Subpart A (pp 1-275 of 550) p. 201-203

Practise the full DHS 2018 shift 1st

Attempt every question from this paper in a timed mock, then review the full solution for each one.