Adllent, 1 day postpartum, is being monitored after a postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
Urine output of 200 mL for the past 8 hours.
Weight decrease of 2 pounds since delivery.
Pulse rate of 65 beats per minute.
Drop in hematocrit of 6% since admission.
The Correct Answer is D
Choice a) Urine output of 200 mL for the past 8 hours is incorrect because this is a normal finding for a postpartum woman. The average urine output for a healthy adult is about 800 to 2000 mL per day, which means about 100 to 250 mL per hour. Therefore, a urine output of 200 mL for the past 8 hours is within the normal range and does not indicate any complications.
Choice b) Weight decrease of 2 pounds since delivery is incorrect because this is also a normal finding for a postpartum woman. The weight loss is due to the expulsion of the placenta, amniotic fluid, and blood during delivery. A postpartum woman can expect to lose about 10 to 12 pounds immediately after giving birth, and another 5 pounds in the following weeks due to fluid loss. Therefore, a weight decrease of 2 pounds since delivery is not a cause for concern and does not need to be reported to the obstetrician.
Choice c) Pulse rate of 65 beats per minute is incorrect because this is also a normal finding for a postpartum woman. The normal resting pulse rate for an adult ranges from 60 to 100 beats per minute, and it may decrease slightly after delivery due to blood loss and reduced cardiac output. Therefore, a pulse rate of 65 beats per minute is not indicative of any problems and does not require any intervention.
Choice d) Drop in hematocrit of 6% since admission is correct because this is an abnormal finding for a postpartum woman and suggests that she has developed anemia due to excessive blood loss. Hematocrit is the percentage of red blood cells in the blood, and it reflects the oxygen-carrying capacity of the blood. The normal hematocrit range for an adult female is 37% to 47%, and it may decrease slightly after delivery due to hemodilution. However, a drop in hematocrit of more than 10% from the baseline or below 30% indicates severe anemia and requires immediate treatment. Therefore, a drop in hematocrit of 6% since admission is a significant change that should be reported to the obstetrician as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.
Correct Answer is D
Explanation
Choice A: This is incorrect because weight less than the 10th percentile (SGA) means that the infant is smaller than expected for the gestational age, but not necessarily low birth weight. SGA infants may have intrauterine growth restriction due to maternal, placental, or fetal factors, but they may also be constitutionally small. SGA infants are at risk for hypoglycemia, hypothermia, polycythemia, and perinatal asphyxia.
Choice B: This is incorrect because weight greater than the 90th percentile means that the infant is larger than expected for the gestational age, but not necessarily high birth weight. Infants with weight greater than the 90th percentile are called large for gestational age (LGA) or macrosomic. LGA infants may have maternal diabetes, genetic factors, or post-term pregnancy as causes, but they may also be constitutionally large. LGA infants are at risk for birth trauma, shoulder dystocia, hypoglycemia, and respiratory distress.
Choice C: This is incorrect because weight between the 10th and 90th percentile means that the infant is appropriate for the gestational age (AGA), but not necessarily normal birth weight. AGA infants have a weight that matches their gestational age and are considered healthy and well-nourished. However, some AGA infants may have low or high birth weight depending on their gestational age at birth.
Choice D: This is the correct answer because low birth weight (LBW) is defined as a weight of 2500g or less at birth, regardless of the gestational age. LBW infants may be preterm (born before 37 weeks of gestation), term (born between 37 and 42 weeks of gestation), or post-term (born after 42 weeks of gestation). LBW infants are at risk for infection, bleeding, jaundice, and neurodevelopmental problems.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today