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 C

Explanation

A. The radiant heat warmer does not prevent brown fat production, which is a normal response to cold exposure in newborns.
B. Shivering is a response to cold and not prevented by the radiant heat warmer.
C. The radiant heat warmer helps prevent cold stress by maintaining the newborn's body temperature.
D. Basal metabolic rate reduction is not a specific concern addressed by the radiant heat warmer.

A. The baby should be carried in the parent’s arms from the room to the nursery B. The mom should request that a second staff member verify the identity of any questionable person C. Because of infant security systems, the baby can be left unattended in the client’s room D. Parents should be told it is safe to posting photographs of their infant on the Internet

Correct Answer is B

Explanation

A. Carrying the baby in the parent's arms enhances security but does not directly address the prevention of abduction.
B. Verifying the identity of any questionable person by a second staff member is a key measure to prevent infant abduction.
C. Leaving the baby unattended in the client's room is not a safe practice and does not contribute to preventing abduction.
D. Posting photographs of the infant on the Internet can compromise the child's security and is not recommended.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

Correct Answer is C

Explanation

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security?

Correct Answer is B

Explanation

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

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A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

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?

Which hormone remains elevated in the immediate postpartum period of the breastfeeding women?

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