A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
Select one:
Contact the physician, as it indicates early DIC.
Contact the physician, as it is a first sign of postpartum eclampsia.
Document the finding as it is a normal finding at this time.
Obtain an order for a CBC, as it suggests postpartum anemia.
The Correct Answer is C
Choice A Reason: Contact the physician, as it indicates early DIC. This is an incorrect answer that confuses a low pulse rate with a high pulse rate. DIC stands for disseminated intravascular coagulation, which is a life-threatening condition where abnormal clotting and bleeding occur simultaneously in the body. DIC can occur as a complication of postpartum hemorrhage, infection, or placental abruption. DIC can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).
Choice B Reason: Contact the physician, as it is a first sign of postpartum eclampsia. This is an incorrect answer that misinterprets a low pulse rate as a sign of hypertension. Postpartum eclampsia is a condition where seizures occur in a woman who has preeclampsia or eclampsia after delivery. Preeclampsia and eclampsia are characterized by high blood pressure and proteinuria in pregnancy. Postpartum eclampsia can cause hypertension (high blood pressure), not hypotension (low blood pressure).
Choice C Reason: Document the finding as it is a normal finding at this time. This is because a pulse rate of 60 beats per minute is within the normal range for an adult and may reflect a physiological adaptation to the postpartum period. During pregnancy, the maternal blood volume and cardiac output increase, which can elevate the pulse rate. After delivery, these parameters gradually return to pre-pregnancy levels, which can lower the pulse rate.
Choice D Reason: Obtain an order for a CBC, as it suggests postpartum anemia. This is an incorrect answer that assumes that a low pulse rate is caused by anemia. Anemia is a condition where the red blood cell count or hemoglobin level is lower than normal, which can impair oxygen delivery to the tissues. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy. Anemia can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.
Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.
Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.
Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.
Correct Answer is B
Explanation
Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a different reflex called the rooting reflex. The rooting reflex is a feeding reflex that helps the newborn locate the nipple and initiate sucking. The rooting reflex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.
Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reflex, which is a primitive reflex that is present at birth and disappears by 3 to 6 months of age. The Moro reflex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reflex consists of four phases: extension, abduction, adduction, and crying.
Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reflex called the tonic neck reflex. The tonic neck reflex is a postural reflex that helps prepare the newborn for voluntary reaching. The tonic neck reflex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm flexed.
Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a different reflex called the Babinski reflex. The Babinski reflex is a neurological reflex that tests for spinal cord integrity. The Babinski reflex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiflex and the other toes to fan out.
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