A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?
900 mL of urine output since the birth.
Temperature 37.6° C (99.6° F).
Reports of excessive sweating.
Blood pressure 80/55 mm Hg.
The Correct Answer is D
Choice A rationale
900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.
Choice B rationale
A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).
Choice C rationale
Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.
Choice D rationale
A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Fetal hypoxia occurs when oxygen delivery to the fetus is compromised. In this client, the contraction pattern of very frequent, prolonged contractions every 1–2 minutes lasting 90–120 seconds results in uterine tachysystole, which reduces uteroplacental blood flow during contractions. Normal contraction frequency is no more than 5 contractions in 10 minutes. Excessive contractions increase uterine tone, decrease relaxation time, and limit oxygen exchange, causing fetal heart rate changes like late decelerations and minimal variability. This leads to fetal hypoxia, a critical risk in labor complicated by these contraction abnormalities.
Rationale for incorrect Response 1 options:
Abruptio placentae is a sudden placental separation causing bleeding and pain, which is not directly indicated here, as there is no vaginal bleeding or sharp pain described.
Uterine tachysystole describes the contraction pattern itself rather than a complication; it is a cause, not the adverse outcome.
Chorioamnionitis is infection of fetal membranes, usually indicated by fever and uterine tenderness, neither present here.
Rationale for incorrect Response 2 options:
Gestational hypertension contributes to fetal risk but is not the immediate cause of the current fetal distress.
Fetal heart rate variability describes fetal condition but does not cause fetal hypoxia; rather, it signals it.
Intrauterine growth restriction indicates chronic fetal compromise but is not the direct cause of acute fetal hypoxia during labor contractions.
Take home points:
- Uterine tachysystole causes reduced oxygen delivery by limiting uterine relaxation time, risking fetal hypoxia.
- Fetal hypoxia manifests as late decelerations and minimal variability on fetal monitoring.
- Abruptio placentae and chorioamnionitis have distinct clinical signs, which differ from those caused by contraction abnormalities.
- Differentiating causes of fetal distress is vital for timely intervention during labor to prevent adverse outcomes.
Correct Answer is ["8"]
Explanation
Step 1 is to convert grams to milligrams. 2 g × (1000 mg ÷ 1 g) = 2000 mg.
Step 2 is to divide the total milligrams needed by the milligrams per tablet. 2000 mg ÷ 250 mg = 8 tablets. The nurse should administer 8 tablets.
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