A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?
900 mL of urine output since the birth.
Temperature 37.6° C (99.6° F).
Reports of excessive sweating.
Blood pressure 80/55 mm Hg.
The Correct Answer is D
Choice A rationale
900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.
Choice B rationale
A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).
Choice C rationale
Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.
Choice D rationale
A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
- Discontinue oxytocin infusion (Expected): The client has contractions every 1–2 minutes lasting 90–120 seconds, indicating uterine tachysystole. Stopping oxytocin is a primary intervention to reduce contraction frequency and duration, preventing further fetal hypoxia.
- Assist with amnioinfusion (Expected): Amnioinfusion can help dilute thick meconium-stained amniotic fluid or relieve cord compression, which can cause late decelerations and minimal variability in FHR. It is often used to improve fetal oxygenation during uterine hyperstimulation.
- Give 500 mL of lactated Ringer’s IV bolus (Expected): Increasing maternal hydration improves uteroplacental perfusion, which can be compromised during frequent contractions. This intervention helps restore blood volume and oxygen delivery to the fetus.
- Place the client in a side-lying position (Expected): Lateral positioning improves uterine blood flow by relieving pressure on the vena cava and optimizing cardiac output and fetal oxygenation.
- Give betamethasone 12 mg IM now (Unexpected): Betamethasone is administered antenatally to accelerate fetal lung maturity in preterm labor (before 34 weeks). This client is at 38 weeks gestation, so corticosteroids are not indicated.
Correct Answer is B
Explanation
Choice A rationale
A sudden gush of amniotic fluid typically indicates rupture of membranes (ROM), which can be spontaneous or induced. While ROM can occur during labor, it is not a direct indicator of uterine rupture, which is a catastrophic event involving the tearing of the uterine wall and often presents with different clinical signs.
Choice B rationale
Hypotension with a blood pressure of 85/40 mm Hg is a critical finding suggesting hypovolemic shock, often due to internal hemorrhage, which is a common consequence of uterine rupture. The sudden loss of maternal blood into the abdominal cavity leads to a rapid decrease in circulating blood volume and subsequent systemic hypotension.
Choice C rationale
Severe bradypnea with a respiratory rate of 10/min is not a primary indicator of uterine rupture. Bradypnea often suggests central nervous system depression, possibly from medication effects or other neurological events, but is not a direct physiological response to the acute blood loss and pain associated with a uterine tear.
Choice D rationale
Palpation of the fetal presenting part in the cervical os is a normal finding during labor progression as the fetus descends. However, if the presenting part is palpated higher or outside the uterus, it can indicate expulsion of the fetus into the abdominal cavity following a complete uterine rupture, which is an abnormal and emergent finding.
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