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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A Reason: Homans' sign. This is an incorrect answer that refers to a diﬀerent sign that is not related to pregnancy. Homans' sign is a sign of deep vein thrombosis (DVT) that occurs when there is pain or discomfort in the calf or popliteal region when the foot is dorsiﬂexed. Homans' sign can be elicited by passive or active movement of the foot, but it is not a reliable or specific indicator of DVT.

Choice B Reason: Chadwick's sign. This is an incorrect answer that refers to a diﬀerent sign of pregnancy that aﬀects the color of the cervix, not the texture. Chadwick's sign is a sign of pregnancy that refers to the bluish or purplish discoloration of the cervix, vagina, and vulva due to increased blood ﬂow and congestion. Chadwick's sign can be observed by visual inspection of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.

Choice C Reason: Goodell's sign. This is because Goodell's sign is a sign of pregnancy that refers to the softening of the cervix due to increased vascularity and edema. Goodell's sign can be detected by digital examination of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.

Choice D Reason: McDonald's sign. This is an incorrect answer that refers to a diﬀerent sign of pregnancy that involves the angle of the uterus, not the cervix. McDonald's sign is a sign of pregnancy that refers to the ease of ﬂexing the body of the uterus against the cervix, which creates an angle of 90 degrees or less. McDonald's sign can be assessed by bimanual examination of the uterus during the first prenatal visit, usually around 7 to 8 weeks of gestation.

A. A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. B. A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. C. A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. D. A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes.

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.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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: