A nurse is assessing a client who gave birth 12 hours ago and is experiencing excessive vaginal bleeding.
Which of the following findings indicates the client is experiencing decreased cardiac output?
Bradycardia.
Flushed face.
Hypotension.
Polyuria.
The Correct Answer is C
Choice A rationale
Bradycardia, or a heart rate below 60 beats per minute, is inconsistent with decreased cardiac output in this context. Tachycardia is a more typical compensatory response to significant blood loss postpartum.
Choice B rationale
A flushed face is not a physiological indicator of decreased cardiac output. Decreased cardiac output commonly leads to pallor and cool, clammy skin due to reduced peripheral perfusion.
Choice C rationale
Hypotension, defined as blood pressure below 90/60 mmHg, occurs due to reduced blood volume and cardiac output in excessive postpartum bleeding, impairing adequate perfusion to organs and tissues.
Choice D rationale
Polyuria, or excessive urination, does not directly indicate decreased cardiac output. Instead, oliguria or decreased urine output, often below 30 mL/hour, is a common sign of poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Elevating the client’s legs increases venous return, but it does not directly address the immediate cause of excessive bleeding, which is most often uterine atony.
Choice B rationale
Inserting a urinary catheter aids bladder emptying, which can support uterine contraction indirectly, but this is not the first action to control active bleeding.
Choice C rationale
Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.
Choice D rationale
Oxytocin administration enhances uterine contractions, but manual fundal massage is typically performed first to assess and manage uterine atony immediately.
Correct Answer is B
Explanation
Choice A rationale
Intravenous medications are not administered for a nonstress test, which evaluates fetal heart rate response to movement using external monitoring. No pharmacological intervention is needed.
Choice B rationale
Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.
Choice C rationale
There are no dietary restrictions for a nonstress test, as the procedure involves non-invasive external monitoring and does not affect digestion or metabolic processes.
Choice D rationale
A nonstress test does not assess fetal lung maturity but evaluates fetal heart rate accelerations in response to fetal movement to ensure fetal well-being.
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