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.
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Related Questions
Correct Answer is A
Explanation
A) Correct - "Progestin-only birth control pills are preferred for contraception during lactation." Progestin-only pills are generally considered safer for breastfeeding mothers as they are less likely to affect milk supply.
B) Incorrect- There is no strong evidence suggesting that taking birth control pills while breastfeeding increases the risk of breast cancer.
C) Incorrect- While breastfeeding can have contraceptive effects, relying solely on breastfeeding for contraception is not a foolproof method. It's recommended to use additional birth control methods if desired.
D) Incorrect- Birth control pills are not contraindicated for breastfeeding clients, especially if they are progestin-only pills. The preferred method, however, is progestin-only rather than combined hormonal pills.
Correct Answer is B
Explanation
A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.
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