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 D

Explanation

The correct answer is choiced. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first.This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

A. March 14 B. March 21 C. March 28 D. April 4

Correct Answer is C

Explanation

Step 1: According to Naegele’s rule, we start with the first day of the last menstrual period, which is June 212.
Step 2: We then subtract three months, which gives us March 212.
Step 3: Finally, we add seven days, which gives us March 282. So, the estimated date of delivery in the next year is March 28.

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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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