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 A
Explanation
A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.
Correct Answer is D
Explanation
A) Incorrect- Using a breast pump can actually help relieve breast engorgement by expressing excess milk, so this advice is not appropriate.
B) Incorrect- Applying ice packs to the breasts can decrease milk production and might not provide as much relief as other interventions.
C) Incorrect- Wearing a supportive, well-fitting bra is a good recommendation, but it might not provide enough relief for breast engorgement on its own.
D) Correct - Applying purified lanolin to the breasts can help soothe and moisturize the nipples, making breastfeeding more comfortable and providing relief from breast engorgement.
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