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
Synchronized breathing is not specifically required during hypnosis. Hypnosis involves a state of deep relaxation and focused concentration.
Choice B rationale
While focusing on controlling body functions can be a part of some relaxation and pain management techniques, it is not the primary component of hypnosis. Hypnosis is more about reaching a state of deep relaxation and altering one’s state of consciousness.
Choice C rationale
Hypnosis can indeed be beneficial if practiced during the prenatal period. Regular practice can help enhance the effectiveness of hypnosis during labor by making it easier for the person to reach the hypnotic state.
Choice D rationale

This statement is not entirely accurate. Hypnosis can be an effective method for managing labor pain for some individuals. However, like all pain management techniques, its effectiveness can vary from person to person.

A. Patient who has a urinary output of 300 ml in 8 hours B. Patient who reports lochia rubra requiring changing perineal pads every 3 hours C. Patient who is receiving magnesium sulfate and has absent deep tendon reflexes D. Patient who reports abdominal cramping during breastfeeding

Correct Answer is C

Explanation

Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

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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

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Explanation

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Correct Answer is C

Explanation

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