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
A. Hypotension, not hypertension, is expected in hemorrhagic shock due to blood loss.
B. Tachypnea, not bradypnea, usually occurs as the body tries to compensate for hypoxia.
C. Tachycardia is an early compensatory response to blood loss to maintain cardiac output.
D. Oliguria (decreased urine output), not polyuria, is expected due to poor perfusion of kidneys in shock.
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Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.
B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.
C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.
D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.
E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.
F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.
G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.
Correct Answer is C
Explanation
A. Assessing for tachysystole is important, but intervention is needed immediately to improve fetal oxygenation.
B. Internal monitoring may provide more accurate data, but it does not address the immediate fetal distress.
C. The first action should be to reposition the client to a left lateral position to improve uteroplacental blood flow and oxygenation to the fetus.
D. Increasing IV fluids can help with placental perfusion, but positioning is faster and more immediately effective.
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