The nurse at a shelter is counseling a group of women experiencing domestic violence. What is most important for the nurse to emphasize?
Select one:

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).

Choice A Reason: Preterm infant. This is an incorrect answer that confuses TTN with another respiratory condition called respiratory distress syndrome (RDS). RDS is a serious condition where the newborn's lungs are immature and lack sufficient surfactant, which is a substance that reduces surface tension and prevents alveolar collapse. RDS can cause respiratory distress, hypoxia, acidosis, and organ failure. It is more common in preterm infants, especially those born before 37 weeks' gestation.

Choice B Reason: Female infant. This is an incorrect answer that has no evidence or rationale to support it. TTN does not have a gender preference or difference in incidence or severity.

Choice C Reason: GBS status of mother. This is an incorrect answer that relates to another respiratory complication called early-onset neonatal sepsis (EONS). EONS is a bacterial infection that occurs within 72 hours after birth, which can affect multiple organs and systems in the newborn. EONS can be caused by group B streptococcus (GBS), which is a common bacterium that colonizes in some women's vagina or rectum. GBS can be transmited to the newborn during delivery and cause pneumonia, meningitis, or septic shock.

Choice D Reason: Cesarean section. This is because cesarean section is a risk factor for TTN, which is a mild respiratory problem that results from delayed clearance of fetal lung fluid after birth. TTN causes rapid breathing, nasal flaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth. Cesarean section can increase the risk of TTN because it bypasses the normal process of labor, which helps squeeze out some of the fluid from the fetal lungs.