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 B
Explanation
Choice A rationale
Difficulty breathing can indicate an anaphylactic reaction, a rare but serious side effect of Hemabate. It involves bronchoconstriction triggered by prostaglandin administration, usually necessitating emergency interventions.
Choice B rationale
Diarrhea is common due to prostaglandin's stimulation of smooth muscle in the gastrointestinal tract, leading to increased motility. This adverse effect often accompanies other systemic effects like cramping.
Choice C rationale
Hypotension, while possible, is less frequent and usually transient. It may result from the vasodilatory properties of prostaglandins but is not a primary side effect.
Choice D rationale
Palpitations occur less commonly and may arise if Hemabate induces systemic changes affecting heart rate, including reflex tachycardia secondary to other hemodynamic shifts.
Correct Answer is D
Explanation
Choice A rationale
Gastric problems later in life are not an immediate concern for infants with myelomeningocele, as they often arise secondary to neurological impairments or medications but do not pose immediate life-threatening risks at birth.
Choice B rationale
Respiratory depression in infants with myelomeningocele is rare unless coexisting brainstem anomalies or complications from anesthesia are present, which are typically managed during medical interventions.
Choice C rationale
Decreased cardiac output is not a primary risk in infants with myelomeningocele unless there is a coexisting cardiac anomaly, which is not a routine feature of this congenital condition.
Choice D rationale
Infection is a critical immediate risk due to the open neural tube defect in myelomeningocele, which exposes the spinal cord and meninges to environmental pathogens, increasing the risk of meningitis or systemic infection.
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