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
Amniotic fluid embolism is a life-threatening emergency that can lead to cardiac and respiratory failure. Immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and oxygenation.
Choice B rationale
Ephedrine is not typically used in the management of amniotic fluid embolism. It is a vasopressor used to treat hypotension, but it is not the primary intervention in this situation.
Choice C rationale
Assessing for the presence of clonus is not relevant in this situation. Clonus is a neurological sign and is not directly related to amniotic fluid embolism.
Choice D rationale
Assisting the client to empty their bladder is not a priority action in this situation. The immediate concern is maintaining the client’s airway, breathing, and circulation.
Correct Answer is C
Explanation
Choice A rationale
Raw carrots do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice B rationale
Fresh citrus fruits do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice C rationale
This is the correct answer. Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamin B12 and other nutrients to help vegans meet their nutritional needs.
Choice D rationale
Brown rice does not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
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