A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?

Tachycardia

Flushed skin

Polyuria

Firm fundus

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.

Choice B rationale:

Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.

Choice C rationale:

Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.

Choice D rationale:

A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.

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Correct Answer is C

Explanation

Choice A rationale:

Administering all the missed immunizations in one injection is not recommended and can lead to increased discomfort and potential adverse reactions.

Choice B rationale:

Starting the immunization series over is unnecessary and can delay the child's protection against vaccine-preventable diseases.

Choice C rationale:

The most appropriate action is to administer the immunizations the child missed at the earliest opportunity to catch up on the schedule.

Choice D rationale:

Waiting until 12 months of age is not necessary if the child has already missed scheduled immunizations. The catch-up schedule should be followed based on the child's current age.

A. Teach the client about manifestations of anxiety. B. Complete the client's assessment. C. Provide reassurance of safety to the client. D. Administer an anti-anxiety medication to the client.

Correct Answer is C

Explanation

Choice A rationale:

Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.

Choice B rationale:

Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.

Choice C rationale:

Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.

Choice D rationale:

Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.

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A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?

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