A nurse is caring for a client who is postpartum. The nurse should identify which of the following finding as an early indicator of hypovolemia caused by hemorrhage?
Increasing pulse and decreasing blood pressure
Dizziness and increasing respiratory rate
Cool, clammy skin, and pale mucous membrane
Altered mental status and level of consciousness
The Correct Answer is A
A. Increasing pulse and decreasing blood pressure: Tachycardia is one of the earliest compensatory responses to hypovolemia, as the body attempts to maintain cardiac output despite reduced circulating volume. A subsequent drop in blood pressure indicates progressing volume loss and cardiovascular compromise.
B. Dizziness and increasing respiratory rate: Dizziness and tachypnea may develop as blood loss continues, but these are slightly later manifestations reflecting decreased oxygen delivery and compensatory respiratory effort rather than the initial physiologic response.
C. Cool, clammy skin, and pale mucous membrane: Peripheral vasoconstriction and pallor are compensatory mechanisms that appear after significant blood volume loss, indicating more advanced hypovolemia.
D. Altered mental status and level of consciousness: Changes in consciousness occur later in hemorrhagic hypovolemia, reflecting cerebral hypoperfusion. These are not the earliest indicators and suggest severe, potentially life-threatening blood loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Herpes: Genital herpes is caused by herpes simplex virus (HSV) and is a lifelong viral infection. Antiviral medications can manage outbreaks and reduce transmission but cannot cure the infection.
B. Acquired imunodeficiency syndrome (AIDS): AIDS is caused by HIV, which is a chronic viral infection. Antiretroviral therapy controls viral replication and improves immune function but does not eradicate the virus.
C. Venereal warts: Caused by human papillomavirus (HPV), genital warts can be treated or removed, but the underlying viral infection may persist. Recurrence is common, and no definitive cure exists.
D. Chlamydia: Chlamydia trachomatis is a bacterial infection that can be effectively treated and cured with antibiotics such as azithromycin or doxycycline when the full course is completed, preventing long-term complications.
Correct Answer is D
Explanation
A. Heart: Heart assessment, including auscultation of rate and rhythm, can be performed while the newborn is calm or sleeping. It does not typically disturb the infant and provides important baseline cardiovascular data early in the examination.
B. Abdomen: Abdominal inspection and palpation can be performed while the newborn is lying quietly. Gentle handling usually does not awaken the infant, and assessing for organ size, tenderness, or masses is best done before more invasive or stimulating procedures.
C. Lungs: Lung auscultation can be done with minimal disturbance to the sleeping newborn, allowing assessment of respiratory rate, breath sounds, and effort without causing agitation. This is often performed after heart and abdominal assessments.
D. Throat: Examination of the throat is invasive and often triggers gagging or crying. Performing it last minimizes disruption to the newborn, ensuring that earlier assessments can be completed while the infant remains calm and asleep.
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