A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively.
Which of the following actions should the nurse take?

Choice A rationale

The human body possesses compensatory mechanisms, such as sympathetic nervous system activation leading to vasoconstriction and increased heart rate, that can maintain vital organ perfusion despite significant blood loss. These mechanisms can mask overt signs of shock, such as hypotension, until approximately 20-25% of the total blood volume (around 1000-1250 mL in an average adult) has been acutely lost. This delay in visible manifestations can be critical in situations like postpartum hemorrhage, where rapid blood loss can occur.

Choice B rationale

Hemorrhagic shock typically leads to a state of metabolic acidosis, not an increase in serum pH. This occurs due to inadequate tissue perfusion, resulting in anaerobic metabolism and the accumulation of lactic acid. The reduced oxygen delivery forces cells to switch from efficient aerobic respiration to less efficient anaerobic glycolysis, producing lactate as a byproduct, which lowers the blood pH. A normal serum pH range is 7.35 to 7.45.

Choice C rationale

While urine output is a valuable indicator of renal perfusion and overall circulatory status, it is not the most accurate or immediate indicator of *overall* organ perfusion. Other parameters like mental status, skin perfusion (capillary refill), and arterial blood pressure (MAP) provide more global and rapid assessments of tissue oxygenation. Urine output primarily reflects renal blood flow, which can be maintained by compensatory mechanisms even when other organs are hypoperfused. Normal urine output is generally considered to be 0.5 to 1 mL/kg/hr.

Choice D rationale

The standard resuscitation guideline for hemorrhagic shock is to administer 3 mL of isotonic crystalloid solution, such as lactated Ringer's, for every 1 mL of estimated blood loss. This 3: ratio accounts for the rapid redistribution of crystalloids from the intravascular space to the interstitial space, meaning that only about one-third remains within the vascular compartment to expand circulating blood volume effectively.

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy for hyperbilirubinemia. Glucose water provides no nutritional benefit, can lead to decreased breast milk intake, and does not aid in the excretion of bilirubin, which is primarily excreted through conjugated bile in stool.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment for hyperbilirubinemia is incorrect. Breastfeeding should be continued and encouraged, as adequate hydration and caloric intake are crucial for promoting bowel movements, which help in the excretion of bilirubin from the body. Interruption of breastfeeding can also negatively impact milk supply.

Choice C rationale

Monitoring intake and output is critical for a newborn undergoing phototherapy. Phototherapy can increase insensible fluid losses through the skin, potentially leading to dehydration. Close monitoring of fluid intake (e.g., breastfeeding, formula) and urine/stool output ensures adequate hydration and helps assess the effectiveness of bilirubin excretion.

Choice D rationale

Applying lotions and ointments throughout phototherapy treatment is contraindicated. These products can absorb the light emitted by the phototherapy unit, leading to potential burns or uneven light distribution on the newborn's skin, thereby reducing the effectiveness of the treatment for hyperbilirubinemia.