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 A

Explanation

A. Proper latch involves placing both the nipple and a portion of the areola into the baby's mouth.
B. While babies have instincts, guidance on proper latch is essential for successful breastfeeding.
C. Placing the nipple and areola under the tongue is not accurate guidance for breastfeeding.
D. Limiting the latch to part of the nipple may lead to ineffective breastfeeding.

A. "My baby's bassinet should be kept away from fans and air conditioning." B. "My baby's temperature will be checked rectally every hour." C. "I should keep my baby's head covered." D. "I should keep my infant swaddled in a warm blanket."

Correct Answer is B

Explanation

A. Keeping the baby's bassinet away from fans and air conditioning is a correct practice to prevent chilling.
B. Checking the baby's temperature rectally every hour is not a standard practice and may lead to unnecessary discomfort for the baby.
C. Keeping the baby's head covered is generally recommended for warmth.
D. Keeping the infant swaddled in a warm blanket is a good practice for maintaining warmth.

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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 is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

Correct Answer is A

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?

Correct Answer is B

Explanation

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 nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??

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?

A new mother states that her infant must be cold because the baby’s hands and feet are blue. This common and temporary condition is called what?

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A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?