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:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.

A. Abdominal distention. B. Jitteriness. C. Acrocyanosis. D. Hypotonia. E. Temperature instability.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

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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 ["B","D","E"]

Explanation

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