Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a postpartum client who just delivered a newborn weighing 4.5 kg (10 lb). Which of the following signs should the nurse recognize as a potential indication of hemorrhage?

A.

Blood pressure 88/40 mm Hg

B.

Moderate rubra lochia

C.

Heart rate 90/min

D.

Urinary output 40 mL/hr

Answer and Explanation

The Correct Answer is A

Choice A rationale
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.
 

Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

Choice A rationale
While magnesium sulfate can have an effect on the fetal heart rate, it does not primarily function to stabilize it. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties.
Choice B rationale
Magnesium sulfate does not primarily function to improve tissue perfusion. Its main role in the management of preeclampsia is to prevent seizures.
Choice C rationale

This is the correct answer. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties. It helps to prevent seizures in those with severe preeclampsia, which can minimize the risk of complications.
Choice D rationale
Magnesium sulfate does not increase cardiac output. Its primary role in the management of preeclampsia is to prevent seizures.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

• Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
• Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
• Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
• Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
• Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
• Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register