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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encouraging the mother to smoke in another room helps reduce the exposure of the newborn to secondhand smoke.
B. The effects of secondhand smoke on infants are significant and can increase the risk of respiratory infections, sudden infant death syndrome (SIDS), and other health issues.
C. There is a clear relationship between smoking and breastfeeding, and smoking during breastfeeding should be minimized.
D. Smoking can affect milk production and composition, and it is advisable for breastfeeding mothers to quit smoking.
Correct Answer is ["50"]
Explanation
To calculate the infusion rate for antibiotic X, the nurse needs to use the formula: gtt/min = (Volume x Drop factor) / Time
Plugging in the values from the question, we get:
gtt/min = (50 mL x 20 gtt/mL) / 20 min Simplifying, we get:
gtt/min = 1000 gtt / 20 min Dividing, we get:
gtt/min = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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