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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","H"]
Explanation
Choice A rationale:
BUN is within the normal range (10 to 20 mg/dL), so it's not an indication of a potential complication.
Choice B rationale:
Potassium is slightly below the normal range (3.5 to 5 mEq/L), indicating potential hypokalemia, which can be a complication.
Choice C rationale:
Hct is at the upper limit of the normal range (33% to 49%), but still within normal, so it's not a complication.
Choice D rationale:
Weight loss of 2 kg in 1 month during pregnancy is concerning and could indicate a complication such as hyperemesis gravidarum.
Choice E rationale:
Heart rate is slightly elevated, which could indicate dehydration, a potential complication.
Choice F rationale:
Sodium is slightly below the normal range (136 to 145 mEq/L), but this alone is not typically a complication of pregnancy.
Choice G rationale:
Hgb is within the normal range (11 to 16 g/dL), so it's not a complication.
Choice H rationale:
Urine-specific gravity is above the normal range (1.005 to 1.030), indicating potential dehydration, a complication.
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.
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