A patient, one day postpartum, is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
Urine output of 40 mL in the last 8 hours.
Drop in hematocrit of 2% since admission.
Weight decrease of 2 lbs since delivery.
Pulse rate of 68 beats per minute.
The Correct Answer is A
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Providing family support is crucial as preterm birth can cause significant emotional distress. Education and involvement aid understanding of interventions and foster a supportive environment for both the neonate and family.
Choice B rationale
Strict handwashing and sterile technique prevent infection in preterm neonates, whose immature immune systems make them highly susceptible to sepsis, a leading cause of morbidity in NICUs.
Choice C rationale
Creating a womb-like state through dim lighting, limited noise, and careful positioning supports neurodevelopment and mimics the intrauterine environment, promoting growth and stability.
Choice D rationale
Frequent diaper changes may disturb thermoregulation and disrupt the neonate's limited energy reserves, as preterm infants require an environment that minimizes stress and conserves energy.
Correct Answer is A
Explanation
Choice A rationale
Visual impairment, including retinopathy of prematurity, results from immature retinal vascularization and oxidative damage caused by prolonged oxygen therapy in premature infants, leading to neovascularization and potential retinal detachment.
Choice B rationale
Sensitivity to touch reflects neurologic immaturity or overstimulation in premature infants but is not directly associated with oxygen therapy. It stems from underdeveloped sensory pathways and an immature central nervous system.
Choice C rationale
Hyperbilirubinemia arises from excessive bilirubin production or impaired hepatic clearance in neonates, unrelated to oxygen therapy. Factors include hemolysis, immature liver enzyme systems, or delayed feeding initiation.
Choice D rationale
Cerebral palsy, a motor disorder due to non-progressive brain injury, can result from perinatal asphyxia or intracranial hemorrhage, but it is not a direct outcome of oxygen therapy in premature infants.
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