A nurse is caring for a client who is postpartum and experiencing hypovolemic shock.
Which of the following findings should the nurse expect?
Cool, clammy skin.
Urinary output 30 mL/hr.
Bounding pulses.
Respiratory rate 18/min.
The Correct Answer is A
A client who is postpartum and experiencing hypovolemic shock would have cool, clammy skin.
This is because hypovolemic shock severely limits the body’s ability to get blood
to all of its organs.
Choice B is not correct because a urinary output of 30 mL/hr is within the
normal range.
Choice C is not correct because a client experiencing hypovolemic shock would have a weak pulse, not a bounding one.
Choice D is not correct because a respiratory rate of 18/min is within the normal range, while a client experiencing hypovolemic shock would have an increased respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A platelet count of 60,000/mm is low and can be a sign of HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelet count), which is a serious complication of preeclampsia.
Choice A is not the answer because a creatinine level of 0.8 mg/dL is within the normal range.
Choice C is not the answer because a hemoglobin level of 148 g/dL is within the normal range.
Choice D is not the answer because urine protein concentration of 200 mg/dL is within the normal range for preeclampsia.
Correct Answer is C
Explanation
Rationales
A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.
B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.
C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up.
D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.
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