A nurse is caring for a client who is receiving fluid replacement therapy following a postpartum hemorrhage. Which of the following findings Indicate the client's fluid balance has been restored?
Peripheral edema is present.
Crackles upon auscultation of the lungs
Maternal heart rate is 110/min.
Urine output for 1 hour is 35 mL.
The Correct Answer is D
Rationale:
A. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.
B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.
C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.
D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The client takes a hot bubble bath every day: Frequent hot bubble baths can irritate the skin and mucous membranes, potentially increasing the risk of infections. Daily bathing is acceptable, but water should be warm rather than hot, and bubble baths should be limited.
B. The client washes her perineum first when bathing: Proper hygiene involves washing from front to back to prevent transferring bacteria from the rectal area to the urethra or vagina. Washing the perineum first without this technique increases the risk of urinary tract infections.
C. The client brushes her teeth twice daily: Brushing teeth twice daily is an appropriate and effective oral hygiene practice. It helps prevent dental plaque, cavities, and gum disease, indicating correct understanding of personal hygiene.
D. The client wipes back to front when toileting: Wiping back to front can transfer fecal bacteria to the urethra and genital area, increasing the risk of urinary tract infections. The correct technique is front to back.
Correct Answer is D
Explanation
Rationale:
A. "Why did this happen to me?": This statement reflects the anger stage of grief, where the client questions fairness and expresses frustration about their situation. It does not involve negotiating or making promises in exchange for a desired outcome.
B. "I never did anything bad to hurt anyone": This reflects the guilt or depression stage, as the client may be feeling remorse or self-blame related to their illness. It is an emotional expression rather than an attempt to bargain.
C. "I hope my family can accept what's happening": This reflects the acceptance stage, where the client begins to come to terms with their prognosis and focuses on reconciliation or emotional resolution.
D. "If I get better I will study to become a priest.": This is an example of the bargaining stage, where the client attempts to negotiate or make promises in exchange for a desired outcome, such as improved health or extended life. It demonstrates the “what if” reasoning characteristic of this stage of grief.
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