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 C
Explanation
A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.
Correct Answer is C
Explanation
A) Incorrect- Tachycardia (elevated heart rate) can be a common physiological response to pain or other factors and is not necessarily indicative of an adverse effect of epidural anesthesia.
B) Incorrect- Fever might be related to various factors, including infection, and is not directly indicative of an adverse effect of epidural anesthesia.
C) Correct - Tachypnea (rapid breathing) can be an adverse effect of epidural anesthesia.
It can indicate that the anesthesia has spread too high in the spinal column, potentially affecting the respiratory muscles and causing respiratory distress.
D) Incorrect- Hypertension might be a side effect of epidural anesthesia, but tachypnea is a more specific indication of an adverse effect in this context.
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