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

Blood pressure 88/40 mm Hg

Moderate rubra lochia

Heart rate 90/min

Urinary output 40 mL/hr

Answer and Explanation

The Correct Answer is A

Choice A rationale
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.

Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale
Joint pain is not a common side effect of the rubella immunization.
Choice B rationale
Breastfeeding is not typically contraindicated after receiving the rubella immunization.
Choice C rationale
Women are advised to avoid becoming pregnant for at least one month following the rubella immunization because the vaccine contains a live virus.

Choice D rationale
The rubella immunization is not typically given as a series of three immunizations.

A. Transmission can occur via the saliva and urine of the newborn. B. This infection requires that airborne precautions be initiated for the newborn. C. Lesions are visible on the mother’s genitalia. D. Mothers receive prophylactic treatment with acyclovir prior to delivery.

Correct Answer is A

Explanation

Choice A rationale
Maternal cytomegalovirus (CMV) infection is a serious health concern as it is associated with severe birth defects like sensori-neural hearing loss, impairment of cognitive development, and cerebral palsy. It is acquired by contact with body fluids and by vertical transmission from mother to fetus. Transmission can occur via the saliva and urine of the newborn, which is why this is the correct answer.
Choice B rationale
CMV does not require airborne precautions. It is not an airborne disease; it is spread through close, direct contact with a person infected with the virus.
Choice C rationale
CMV does not cause visible lesions on the mother’s genitalia. This is a characteristic of other sexually transmitted infections, not CMV2.
Choice D rationale
Mothers do not receive prophylactic treatment with acyclovir prior to delivery to prevent CMV2. Acyclovir is an antiviral medication used to treat herpes simplex virus infections, not CMV2.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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