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 B
Explanation
Choice A) Wrap the cord loosely with a sterile towel saturated with warm normal saline: This is not an appropriate action because it does not relieve the compression of the cord, which can cause fetal hypoxia and acidosis. The cord should be kept moist, but not wrapped around anything.
Choice B) Place a sterile gloved hand into the vagina and hold the presenting part off the cord while calling for assistance: This is the correct action because it prevents further descent of the fetus and reduces the pressure on the cord, which can improve fetal oxygenation and blood flow. The nurse should also elevate the woman's hips and place her in a knee-chest or Trendelenburg position to reduce gravity. The nurse should call for immediate assistance and prepare for an emergency cesarean section.
Choice C) Increase the IV drip rate: This is not an appropriate action because it does not address the cause of the variable decelerations, which is cord compression. Increasing the IV fluid may cause fluid overload and worsen maternal and fetal outcomes.
Choice D) Administer oxygen to the woman via mask at 8 to 10 L/minute: This is not an appropriate action because it does not relieve the cord compression, which is the main threat to fetal well-being. Oxygen administration may be helpful in some cases of fetal distress, but it is not sufficient in this situation.
Correct Answer is D
Explanation
A. Dressing the infant in only a T-shirt and diaper is not recommended during phototherapy because it reduces the amount of skin exposed to the light, which is necessary for effective treatment. The infant should be minimally clothed to maximize light exposure.
B. Restricting parental and oral fluids is incorrect. Adequate hydration is crucial during phototherapy to prevent dehydration, as the treatment can increase fluid loss through the skin.
C. Keeping the infant supine at all times is not necessary. The infant should be repositioned frequently to ensure all areas of the skin are exposed to the phototherapy light, which helps in reducing bilirubin levels more effectively.
D. Keeping the infant's eyes covered under the light is essential to protect the eyes from potential damage caused by the intense phototherapy light. This is a standard practice to prevent retinal damage and other eye complications.
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