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
Leukorrhea, or vaginal discharge, is a common occurrence in pregnancy due to hormonal changes, but it is not a specific sign of abruptio placentae.
Choice B rationale

Hypertension can be a risk factor for abruptio placentae, but it is not a direct sign of the condition.
Choice C rationale
Uterine tenderness is a common symptom of abruptio placentae. This condition, which involves the premature separation of the placenta from the uterus, can cause the uterus to become irritable and sensitive to touch.
Choice D rationale
Fetal tachycardia can be a sign of fetal distress, which could be a result of various complications in pregnancy, including abruptio placentae. However, it is not a specific sign of abruptio placentae.

A. Uterine hypertonicity B. Painless vaginal bleeding C. Persistent headache D. Fetal distress

Correct Answer is B

Explanation

Choice A rationale
Uterine hypertonicity is not typically associated with placenta previa. Hypertonicity refers to an overly active uterus with contractions that are too strong, too long, or too close together.
Choice B rationale
Painless vaginal bleeding is a classic symptom of placenta previa. The bleeding is usually bright red and can be heavy.
Choice C rationale

Persistent headache is not a typical symptom of placenta previa. It is more commonly associated with conditions like preeclampsia.
Choice D rationale
Fetal distress is not a direct symptom of placenta previa, but it can occur if the placenta is not providing enough oxygen and nutrients to the fetus.

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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

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