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. The nurse should not allow anyone other than the mother or the father to take the newborn to the mother's room. This is to prevent infant abduction, which is a serious threat in hospitals. The nurse should also verify the identity of the mother or the father before handing over the newborn. The nurse should instruct the grandmother to have the mother call and request for the newborn to be brought to her room.
B. This is incorrect because pushing the baby in a wheeled bassinet is not a secure way of transporting the newborn. The bassinet could be easily taken by someone else or accidentally rolled away. The nurse should always accompany the newborn when moving from one place to another.
C. This is incorrect because carrying the grandchild to the room is also not a secure way of transporting the newborn. The grandmother could be stopped by someone who claims to be a staff member and asked to hand over the newborn. The nurse should never let anyone carry the newborn without proper identification and authorization.
D. This is incorrect because showing photo identification is not enough to prove that the person is related to the newborn. The nurse should only allow the mother or the father to take the newborn, and only after verifying their identity with a wristband or a code. The nurse should not rely on photo identification alone, as it could be forged or stolen.
Correct Answer is A
Explanation
A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.
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