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
Terbutaline, a medication used to suppress preterm labor, can cause heart palpitations as an adverse effect. This is due to its action as a beta-adrenergic agonist, which can increase heart rate.
Choice B rationale
Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. Terbutaline is more likely to cause tachycardia, or a fast heart rate.
Choice C rationale
Hot flashes are not a common adverse effect of terbutaline. They are more commonly associated with hormonal changes, such as those that occur during menopause.
Choice D rationale
Shortness of breath is not a typical adverse effect of terbutaline. However, if it occurs, it could indicate a serious condition like pulmonary edema and should be reported immediately.
Correct Answer is A
Explanation
Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale
Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
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