A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

Blood pressure 88/40 mm Hg.

Urinary output 40 mL/hr.

Moderate rubra lochia.

Heart rate 90/min.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.

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Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

A. WBC count 9,000/mm. B. Uterine tenderness. C. Scant lochia. D. Temperature 37.4° C (99.3° F).

Correct Answer is B

Explanation

Choice A rationale:
A WBC count of 9,000/mm is within the normal range (4,500-11,000/mm).
Choice B rationale:
Uterine tenderness is a common symptom of endometritis.
Choice C rationale:
Scant lochia is not typically associated with endometritis.
Choice D rationale:
A temperature of 37.4° C (99.3° F) is within the normal range.

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A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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