A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago.
Which of the following manifestations is a possible indication of postpartum hemorrhage?
Respiratory rate 32/min
Temperature 38.3° C (101°F)
Apical pulse 66/min
Blood pressure 156/80 mm Hg
The Correct Answer is A
A) Correct - An elevated respiratory rate could indicate postpartum hemorrhage as the body compensates for decreased oxygen-carrying capacity due to blood loss.
B) Incorrect- An elevated temperature might indicate infection, but it is not a specific indication of postpartum hemorrhage.
C) Incorrect- A normal apical pulse rate does not specifically indicate or rule out postpartum hemorrhage.
D) Incorrect- An elevated blood pressure might occur for various reasons postpartum, including anxiety or pain, but it is not a specific indication of postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","H"]
Explanation
A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.
Correct Answer is A
Explanation
A) Correct - Lochia serosa, a pinkish-brown vaginal discharge, is typically present 24 hours after vaginal delivery. It is the second stage of lochia that follows the bright red lochia rubra.
B) Incorrect- Frequent urges to urinate might be present but are not specific to the 24- hour postpartum period.
C) Incorrect- The uterine fundus should be descending in the days after childbirth, not located 2 finger widths above the umbilicus.
D) Incorrect- Colostrum is the early milk produced by the breasts, but its presence is not a specific finding in the immediate postpartum period.
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