A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock.
Which of the following findings should the nurse expect?
Hypertension.
Bradypnea.
Tachycardia.
Polyuria.
The Correct Answer is C
Choice A rationale
Hemorrhagic shock results from significant blood loss, leading to decreased circulating blood volume and subsequent hypotension. Therefore, hypertension is not expected; instead, the nurse should anticipate hypotension as a classic sign, indicating the body's compensatory mechanisms are failing to maintain adequate perfusion. Systolic blood pressure below 90 mmHg is a common indicator of shock.
Choice B rationale
Initial compensatory mechanisms in shock, driven by the sympathetic nervous system, usually include tachypnea (increased respiratory rate) to enhance oxygenation and address resulting metabolic acidosis. Bradypnea (abnormally slow respiratory rate, normal 12-20 breaths/min) is a late and ominous sign, reflecting profound central nervous system depression and circulatory failure.
Choice C rationale
Tachycardia (heart rate >100 beats/min) is an early and compensatory sign of hemorrhagic shock, triggered by the release of catecholamines (epinephrine, norepinephrine). The sympathetic nervous system increases the heart rate and contractility to compensate for the reduced stroke volume caused by the hypovolemia and maintain cardiac output and tissue perfusion.
Choice D rationale
Hemorrhagic shock causes a severe reduction in renal blood flow due to vasoconstriction and low systemic pressure. This results in oliguria (urine output <30 mL/hr) or anuria, not polyuria. Decreased urine output is a critical indicator of inadequate perfusion to the kidneys and is a classic finding in progressing shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The car seat harness straps should be positioned at or slightly below the baby's shoulders when the car seat is installed rear-facing. Positioning the straps above the shoulders could allow the baby to slide up and out of the harness in a crash due to the forces involved, compromising the restraint system's effectiveness and increasing injury risk.
Choice B rationale
The retainer clip, also called the chest clip, must be positioned at the level of the armpits across the center of the chest or sternum, not the abdomen. This critical placement ensures that the harness straps are kept correctly positioned over the baby's shoulders, preventing the straps from slipping off during a collision and maintaining optimal force distribution across the torso.
Choice C rationale
A 45-degree recline angle for a rear-facing car seat is generally recommended to prevent the infant's head from falling forward, which can compromise the airway, particularly in newborns or infants with poor head control. This specific angle is crucial for maintaining a safe and open airway and is often achieved using built-in level indicators on the car seat base.
Choice D rationale
Current safety recommendations advise keeping a child in a rear-facing car seat as long as possible, typically until they reach the maximum weight or height limit allowed by the car seat manufacturer, which often extends well beyond 12 months of age, frequently up to 2 to 4 years of age, for maximum spinal protection.
Correct Answer is A
Explanation
Choice A rationale
The umbilical cord stump typically dries, shrivels, and spontaneously separates from the infant's abdomen due to a process similar to dry gangrene (ischemic necrosis) within one to three weeks after birth; therefore, this statement indicates correct understanding of the normal timeline for cord care and healing.
Choice B rationale
A newborn's skin is sensitive and prone to drying, and daily tub baths are unnecessary and may cause skin irritation; sponge baths are used until the cord stump falls off, and then typically only two to three baths per week are recommended initially to maintain skin integrity.
Choice C rationale
The correct procedure for using a bulb syringe is to compress the bulb before insertion into the mouth (or nose) to create the negative pressure, then release the compression slowly to suction mucus; compressing it after insertion would expel air into the baby's mouth instead of suctioning.
Choice D rationale
Placing a baby on their side to sleep increases the risk of the baby rolling onto their stomach, which is associated with an elevated risk of Sudden Infant Death Syndrome (SIDS); the universally recommended safe sleep position is supine (on the back).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.