A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock.
Which of the following statements should the charge nurse make?

Manifestations of shock might not appear until a client loses 20% of their blood volume.

Hemorrhagic shock will cause an increase in a client's serum pH.

The most accurate indication of organ perfusion is a client's urine output.

An infusion of 1 mL of lactated Ringers is given for each 1 mL of blood loss.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C

Choice A rationale: Clinical manifestations of hypovolemic shock typically begin when approximately 15% to 30% of total blood volume is lost. In pregnancy, total blood volume increases by about 30% to 50%, so signs may be masked initially. However, waiting until 20% loss to expect symptoms is misleading. Tachycardia, pallor, and hypotension may appear earlier. Therefore, this statement underestimates the sensitivity of maternal physiology to blood loss and is not scientifically accurate.

Choice B rationale: Hemorrhagic shock leads to tissue hypoperfusion and anaerobic metabolism, resulting in lactic acid accumulation and metabolic acidosis. This causes a decrease in serum pH, not an increase. Normal serum pH ranges from 7.35 to 7.45. In shock states, pH often drops below 7.35, indicating acidosis. An increase in pH would suggest alkalosis, which is not consistent with the pathophysiology of hemorrhagic shock. Thus, this statement contradicts basic acid-base science.

Choice C rationale: Urine output is a direct and sensitive indicator of renal perfusion and overall organ perfusion. The kidneys require adequate blood flow to maintain glomerular filtration. In shock, decreased cardiac output reduces renal perfusion, leading to oliguria. Normal urine output is ≥30 mL/hr. Persistent reduction below this threshold reflects compromised perfusion. Unlike blood pressure or heart rate, urine output is less influenced by compensatory mechanisms, making it a reliable marker of end-organ function.

Choice D rationale: Fluid resuscitation in hemorrhagic shock typically involves a 3:1 ratio of isotonic crystalloid (e.g., lactated Ringer’s) to blood loss volume. This accounts for the distribution of fluid into the interstitial and intracellular compartments. Administering only 1 mL of fluid per 1 mL of blood loss is insufficient to restore intravascular volume. The 3:1 replacement rule is based on fluid dynamics and vascular compartmentalization. Therefore, this statement misrepresents standard resuscitation protocols.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

A. Monitor blood pressure every 30 minutes following epidural placement. B. Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement. C. Administer oxygen via nasal cannula at 2 L/min prior to epidural placement. D. Reposition the client every hour following epidural placement.

Correct Answer is B

Explanation

Choice A rationale

Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.

Choice B rationale

Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation, leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.

Choice C rationale

Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to treat or prevent hypoxia, which is not a primary concern in this scenario.

Choice D rationale

Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial action to take for preventing hypotension.

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A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock.
Which of the following statements should the charge nurse make?