A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?
Tachycardia
Flushed skin
Polyuria
Firm fundus
The Correct Answer is A
Choice A rationale:
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
Choice B rationale:
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
Choice C rationale:
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
Choice D rationale:
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
Correct Answer is D
Explanation
Choice A rationale:
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
Choice B rationale:
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
Choice C rationale:
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack
on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
Choice D rationale:
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
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