A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?
Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg
Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg
Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg
Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg
The Correct Answer is D
A. While the heart rate and respiratory rate are elevated, the blood pressure and temperature are within an acceptable range.
B. The heart rate and respiratory rate are within normal limits, and the blood pressure is elevated but not as concerning as other options.
C. The temperature and blood pressure are within normal limits, and while the heart rate is slightly elevated, it is not as concerning as other options.
D. The elevated heart rate, low blood pressure, and elevated temperature may indicate hypovolemic shock, which is of greatest concern given the history of significant estimated blood loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
B. A respiratory rate of 100/min is too high for a newborn and may indicate respiratory distress.
C. A respiratory rate of 22/min is too low for a newborn.
D. A normal respiratory rate for a newborn is between 40 and 60 breaths per minute.
Correct Answer is D
Explanation
A. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.
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