A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago.
Which of the following manifestations is a possible indication of postpartum hemorrhage?
Respiratory rate 32/min
Temperature 38.3° C (101°F)
Apical pulse 66/min
Blood pressure 156/80 mm Hg
The Correct Answer is A
A) Correct - An elevated respiratory rate could indicate postpartum hemorrhage as the body compensates for decreased oxygen-carrying capacity due to blood loss.
B) Incorrect- An elevated temperature might indicate infection, but it is not a specific indication of postpartum hemorrhage.
C) Incorrect- A normal apical pulse rate does not specifically indicate or rule out postpartum hemorrhage.
D) Incorrect- An elevated blood pressure might occur for various reasons postpartum, including anxiety or pain, but it is not a specific indication of postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.
Correct Answer is ["B","C","E"]
Explanation
A) Incorrect- Dry, cracked skin is not typically associated with a newborn born at 43 weeks of gestation. It's more common in post-term babies.
B) Correct - Hypotonia (low muscle tone) is a possible finding in post-term newborns due to the aging placenta and potential decrease in amniotic fluid.
C) Correct - Excessive lanugo (fine, downy hair) is more likely to be present in post-term babies as they have less vernix to protect their skin.
D) Incorrect- Absent vernix might be more characteristic of a post-term newborn, but its presence or absence varies widely.
E) Correct - Long, hard nails can be a characteristic of post-term babies, as they have had more time for nail growth in the womb.
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