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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.

A. The nurse should immediately notify the pediatrician for this emergency situation B. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth C. The neonate must have aspirated surfactant D. If this baby was born vaginally, then a pneumothorax could be indicated

Correct Answer is B

Explanation

A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

Correct Answer is B

Explanation

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