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A nurse is assessing a client that delivered 1 hour ago. Which of the following findings is an early indication of hypovolemic shock?

A.

Dry skin

B.

Alert and oriented

C.

Urinary output below 30 mL/hr

D.

Hypotension

Answer and Explanation

The Correct Answer is C

A. Dry skin is a late sign of hypovolemic shock. Early shock often presents with normal skin turgor, and pallor or cool, clammy skin develops as the body compensates.
B. Being alert and oriented is expected in the early stages of hypovolemic shock because mental status changes occur later when perfusion to the brain is compromised.
C. Urinary output below 30 mL/hr is an early indication of hypovolemic shock. The kidneys are highly sensitive to decreased perfusion, and oliguria occurs as the body conserves fluid and maintains blood pressure, making this one of the first measurable signs of shock.
D. Hypotension is a late sign of hypovolemic shock. The body initially compensates with increased heart rate and vasoconstriction to maintain blood pressure, so a drop in blood pressure indicates advanced shock.


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Related Questions

Correct Answer is A

Explanation

A. Subinvolution of the uterus is the most common cause of late postpartum hemorrhage, which occurs more than 24 hours after delivery (often 1–6 weeks postpartum). It is commonly related to retained placental fragments or infection, leading to failure of the uterus to return to its normal size and tone, resulting in excessive bleeding.
B. Cervical lacerations typically cause early postpartum hemorrhage immediately after birth and are associated with a firm uterus and continuous bleeding, not late PPH.
C. Uterine inversion is a rare, acute obstetric emergency that occurs shortly after delivery and causes early postpartum hemorrhage, severe pain, and shock.
D. Defective vascularity of the placenta is not a typical cause of late postpartum hemorrhage; placental abnormalities are more commonly associated with antepartum or early postpartum bleeding.

Correct Answer is B

Explanation

A. Skipping feedings is not recommended. Missing feedings can worsen engorgement by allowing milk to accumulate, increase discomfort, and may contribute to blocked ducts or mastitis. Regular milk removal is essential to relieve pressure.

B. Breastfeeding 8 to 12 times in 24 hours helps reduce engorgement by emptying the breasts regularly, stimulating milk flow, and preventing stasis. Frequent nursing ensures effective milk removal, decreases swelling and discomfort, and helps maintain a healthy milk supply. Positioning the infant to ensure complete drainage of each breast also aids in relieving engorgement.

C. Avoiding a breast pump is incorrect. Pumping can be used as an adjunct if the infant is unable to fully empty the breasts or if the mother experiences excessive engorgement. Proper pumping technique can help relieve pressure and maintain milk supply.

D. Reducing fluid intake is not recommended. Adequate hydration is important for milk production and maternal health. Decreasing fluids will not reduce engorgement and may negatively affect milk supply and maternal well-being.

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