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
Acyclovir is an antiviral medication used primarily to treat herpes simplex virus (HSV) infections to prevent vertical transmission to the neonate. Group B Streptococcus (GBS) is a bacterium and is treated with antibiotics, specifically penicillin or ampicillin, administered intravenously during labor and delivery to prevent neonatal sepsis.
Choice B rationale
The Group B Streptococcus (GBS) culture is typically collected as a single screen between 36 weeks 0 days and 37 weeks 6 days of gestation from the lower vagina and perirectal area. This one-time positive result is sufficient to indicate the need for intrapartum antibiotic prophylaxis (IAP); repeat testing 24 hours later is not standard practice.
Choice C rationale
If the Group B Streptococcus (GBS) culture is positive, the client is considered colonized and requires intrapartum antibiotic prophylaxis (IAP), usually penicillin G, administered intravenously at the onset of labor or rupture of membranes. This reduces the risk of GBS transmission to the newborn, which can cause severe neonatal morbidity like sepsis or pneumonia.
Choice D rationale
The Group B Streptococcus (GBS) culture is a screening test obtained via a swab of the client's lower vagina and perirectal area, not a blood test. The GBS bacteria colonize these areas, and the swab is sent for culture and sensitivity to determine the need for prophylactic antibiotics during labor.
Correct Answer is ["A"]
Explanation
Answer is: Oral temperature 38.3° C (101° F)
This client is at 30 weeks’ gestation and presenting in preterm labor with uterine contractions, cervical change, and leakage of amniotic fluid. Her vital signs are mostly within normal limits for pregnancy, except for the elevated temperature of 38.3° C, which indicates maternal fever. Fever in a client with preterm labor is concerning because it may suggest intra-amniotic infection (chorioamnionitis), which increases risk for maternal sepsis, fetal infection, and preterm birth complications.
Other vital signs are within normal physiological ranges for pregnancy:
- Heart rate 98/min (slightly elevated but can be normal in pregnancy)
- Respiratory rate 18/min (normal)
- Blood pressure 112/59 mm Hg (normal)
- SaO₂ 98% on room air (normal)
Take-home point: In preterm labor, a maternal fever is a key warning sign that warrants prompt evaluation and interventions to prevent complications for both mother and fetus.
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