A nurse is planning to administer misoprostol 50 mcg intravaginally for cervical ripening to a client who is at 40 weeks of gestation.

Available is misoprostol 200 mcg tablets. How many tablets should the nurse plan to administer?

Choice A rationale

Bladder distention upon palpation indicates urinary retention, meaning the client is unable to void effectively or empty the bladder completely. In the postpartum period, a full bladder can inhibit uterine contraction and increase the risk of postpartum hemorrhage because a distended bladder displaces the uterus, preventing it from clamping down appropriately. The normal range for post-void residual volume is typically less than 100 mL.

Choice B rationale

Not feeling the urge to urinate may be due to decreased bladder sensation following labor and delivery or effects of regional anesthesia, which can lead to urinary retention. Effective voiding is characterized by the ability to sense the urge to void, initiate urination, and empty the bladder, typically passing at least 150 mL per void after catheter removal.

Choice C rationale

Lateral displacement of the uterus is a common sign of a distended bladder. A full bladder pushes the uterus out of its normal midline position, impairing its ability to contract effectively, which increases the risk for uterine atony and subsequent postpartum hemorrhage. The fundus should remain firm and in the midline position after effective voiding.

Choice D rationale

The firming of the fundus with massage indicates that the uterus is contracting, which is essential for preventing postpartum hemorrhage by compressing the blood vessels at the placental site. Effective voiding allows the uterus to remain in its midline position, facilitating proper involution and contractility, which is reflected by a firm fundus.

Choice A rationale

Hemorrhagic shock results from significant blood loss, leading to decreased circulating blood volume and subsequent hypotension. Therefore, hypertension is not expected; instead, the nurse should anticipate hypotension as a classic sign, indicating the body's compensatory mechanisms are failing to maintain adequate perfusion. Systolic blood pressure below 90 mmHg is a common indicator of shock.

Choice B rationale

Initial compensatory mechanisms in shock, driven by the sympathetic nervous system, usually include tachypnea (increased respiratory rate) to enhance oxygenation and address resulting metabolic acidosis. Bradypnea (abnormally slow respiratory rate, normal 12-20 breaths/min) is a late and ominous sign, reflecting profound central nervous system depression and circulatory failure.

Choice C rationale

Tachycardia (heart rate >100 beats/min) is an early and compensatory sign of hemorrhagic shock, triggered by the release of catecholamines (epinephrine, norepinephrine). The sympathetic nervous system increases the heart rate and contractility to compensate for the reduced stroke volume caused by the hypovolemia and maintain cardiac output and tissue perfusion.

Choice D rationale

Hemorrhagic shock causes a severe reduction in renal blood flow due to vasoconstriction and low systemic pressure. This results in oliguria (urine output <30 mL/hr) or anuria, not polyuria. Decreased urine output is a critical indicator of inadequate perfusion to the kidneys and is a classic finding in progressing shock.