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 ["120"]

Explanation

To calculate the infusion rate in gtt/min, the nurse needs to use the formula: gtt/min = (mL/hr x drop factor) / 60

Plugging in the given values, we get:

gtt/min = (120 mL/hr x 60 gtt/mL) / 60

gtt/min = 7200 gtt/hr / 60 gtt/min = 120 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 120 gtt/min.

A. Vitamin K is not initially synthesized because of a sterile bowel at birth B. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice. C. Vitamin K is important in the production of white blood cells D. Vitamin K is important in the production of red blood cells

Correct Answer is A

Explanation

A. Vitamin K is a fat-soluble vitamin that is essential for blood clotting. Newborns have low levels of vitamin K because they do not have the intestinal bacteria that produce it. Therefore, they are given an injection of vitamin K shortly after birth to prevent bleeding disorders.
B. Vitamin K is not crucial for the breakdown of bilirubin.
C. Vitamin K primarily plays a role in blood clotting, not the production of white blood cells.
D. Vitamin K is not directly involved in the production of red blood cells.

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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

Correct Answer is ["120"]

Explanation

The nurse is cognizant of which information related to the administration of vitamin K?

Correct Answer is A

Explanation

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