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).
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.
Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.
Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and effectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.
Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.
Correct Answer is A
Explanation
Choice A Reason: Place the infant skin to skin with the mother and re-check temperature in 30 minutes. This is because skin-to-skin contact is an effective and safe method of increasing the infant's temperature and promoting thermoregulation. Skin-to-skin contact also has other benefits such as enhancing bonding, breastfeeding, and maternal-infant attachment.
Choice B Reason: Check the infant's CBC and blood cultures, as this is a sign of probable sepsis. This is an unnecessary action that may cause undue stress and discomfort to the infant and the mother. A slightly decreased temperature in a full-term infant is not a sign of probable sepsis, but rather a common finding that may be due to environmental factors, such as exposure to cold air or wet linens.
Choice C Reason: Return the infant to the nursery for close observation under warming lights. This is an undesirable action that may interfere with the early initiation of breastfeeding and bonding between the mother and the infant. Warming lights are not recommended for routine use in healthy newborns, as they may cause dehydration, hyperthermia, or eye damage.
Choice D Reason: Notify the physician immediately and suggest orders for placement in an incubator. This is an excessive action that may indicate a lack of knowledge or confidence on the part of the nurse. An incubator is not indicated for a stable, full term infant with a slightly decreased temperature, as it may expose the infant to unnecessary interventions, infections, or separation from the mother.
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