A nurse is teaching a client who is at risk for postpartum hemorrhage about the signs and symptoms of hypovolemic shock.
Which of the following should the nurse include in the teaching? (Select all that apply)
Tachycardia
Hypertension
Pallor
Oliguria
Confusion
Correct Answer : A,C,D,E
The correct answer is choice A, C, D and E. These are the signs and symptoms of hypovolemic shock, which is a life-threatening condition caused by severe blood loss. Hypovolemic shock can occur in postpartum women who have postpartum hemorrhage (PPH), which is excessive bleeding after childbirth.
Choice B is wrong because hypertension is not a sign of hypovolemic shock. In fact, hypotension (low blood pressure) is one of the signs of hypovolemic shock.
Normal ranges for vital signs in postpartum women are:
• Heart rate: 60 to 100 beats per minute
• Blood pressure: 110/70 to 140/90 mmHg
• Respiratory rate: 12 to 20 breaths per minute
• Urine output: at least 30 mL per hour
Question 34.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Massaging the uterine fundus gently is the first action that the nurse should take to stimulate uterine contractions and control bleeding due to uterine atony.Uterine atony is the most common cause of postpartum hemorrhage and occurs when the uterus fails to contract after delivery.
Choice A is wrong because administering oxytocin as prescribed is a secondary action that can be taken after massaging the uterine fundus if bleeding persists.Oxytocin is a medication that promotes uterine contraction and reduces blood loss.
Choice C is wrong because starting an intravenous line with a large bore catheter is a tertiary action that can be taken after massaging the uterine fundus and administering oxytocin if bleeding continues.An intravenous line can provide fluid replacement and blood transfusion if needed.
Choice D is wrong because placing the client in a side lying position is not a priority action for postpartum hemorrhage due to uterine atony.This position may help reduce pressure on the vena cava and improve blood flow, but it does not address the underlying cause of bleeding.
Correct Answer is A
Explanation
Methylergonovine is a medication that stimulates uterine contractions and helps prevent or treat postpartum hemorrhage due to uterine atony or retained placental fragments.However, it can also cause an increase in blood pressure, so the nurse should monitor the client’s blood pressure before and after giving the medication.
Choice B. Temperature is wrong because methylergonovine does not affect the client’s temperature.
Choice C. Respiratory rate is wrong because methylergonovine does not affect the client’s respiratory rate.
Choice D. Oxygen saturation is wrong because methylergonovine does not affect the client’s oxygen saturation.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressures respectively.
Normal ranges for temperature are 36.5°C to 37.5°C or 97.7°F to 99.5°F.
Normal ranges for respiratory rate are 12 to 20 breaths per minute.Normal ranges for oxygen saturation are 95% to 100%.
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