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 A

Choice A rationale

Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.

Choice B rationale

Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.

Choice C rationale

The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator of organ perfusion.

Choice D rationale

An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.

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Correct Answer is ["B","C","D","E","F"]

Explanation

B. "You may experience a headache after receiving this medication."

Some tocolytic medications can cause headaches as a side effect.

C. "It is common for this medication to make you feel jittery."

Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."

The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.

E. "I'll check your reflexes frequently while you are receiving this medication."

Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.

F. "This medication can make your heart beat faster."

Tocolytic medications, such as terbutaline, can increase heart rate.

These statements provide the client with a comprehensive understanding of the purpose of the medication and its potential side effects.

The incorrect statements are:

A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
G. "This medication can increase your blood pressure.": Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.

A. Cool the newborn's heel prior to the procedure. B. Puncture the center of the newborn's heel. C. Cleanse the puncture site with alcohol gauze prior to the procedure. D. Administer vitamin K 30 minutes prior to each blood draw.

Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

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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

A nurse is caring for a 28-year-old female client who is gravida 1 para 0 at 32 weeks of gestation in the prenatal unit. Exhibits The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is planning to obtain a blood specimen from a newborn via a heel stick.Which of the following actions should the nurse take?

Correct Answer is C

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?