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?
Blood pressure 88/40 mm Hg
Moderate rubra lochia
Heart rate 90/min
Urinary output 40 mL/hr
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Uterine tenderness is a common symptom of endometritis, which is an inflammation or irritation of the lining of the uterus.
Choice B rationale
While a high WBC count can be an indicator of infection, a count of 9,000/mm is within the normal range.
Choice C rationale
Scant lochia is not typically associated with endometritis. In fact, women with endometritis may experience heavy lochia or prolonged bleeding.
Choice D rationale
A temperature of 37.4 C (99.3 F) is within the normal range. Endometritis is often associated with fever. .
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and dehydration during pregnancy. The client's laboratory results show signs consistent with dehydration and electrolyte imbalances, such as a low potassium level (3.3 mEq/L) and an elevated blood urea nitrogen (BUN) level (28 mg/dL).
Additionally, the presence of ketones in the urine (not explicitly mentioned in the provided laboratory results but commonly associated with hyperemesis gravidarum) indicates that the body is breaking down fat for energy due to inadequate oral intake and dehydration.
These findings suggest that the client is experiencing significant fluid and electrolyte disturbances, which are commonly seen in hyperemesis gravidarum. Therefore, the client is at risk of developing hyperemesis gravidarum based on the laboratory results indicating dehydration and electrolyte imbalances.
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