A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?
Blood pressure 88/40 mm Hg.
Urinary output 40 mL/hr.
Moderate rubra lochia.
Heart rate 90/min.
The Correct Answer is A
Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
Correct Answer is B
Explanation
Choice A rationale:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.
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