A patient, one day postpartum, is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
Urine output of 40 mL in the last 8 hours.
Drop in hematocrit of 2% since admission.
Weight decrease of 2 lbs since delivery.
Pulse rate of 68 beats per minute.
The Correct Answer is A
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Visual impairment, including retinopathy of prematurity, results from immature retinal vascularization and oxidative damage caused by prolonged oxygen therapy in premature infants, leading to neovascularization and potential retinal detachment.
Choice B rationale
Sensitivity to touch reflects neurologic immaturity or overstimulation in premature infants but is not directly associated with oxygen therapy. It stems from underdeveloped sensory pathways and an immature central nervous system.
Choice C rationale
Hyperbilirubinemia arises from excessive bilirubin production or impaired hepatic clearance in neonates, unrelated to oxygen therapy. Factors include hemolysis, immature liver enzyme systems, or delayed feeding initiation.
Choice D rationale
Cerebral palsy, a motor disorder due to non-progressive brain injury, can result from perinatal asphyxia or intracranial hemorrhage, but it is not a direct outcome of oxygen therapy in premature infants.
Correct Answer is B
Explanation
Choice A rationale
Denying parents the ability to hold their infant can interfere with bonding. Physiologically stable infants on oxygen benefit from being held, as it supports emotional well-being and parent-infant attachment without compromising oxygen delivery.
Choice B rationale
Holding a physiologically stable infant during gavage feeding fosters bonding, reduces parental anxiety, and stabilizes the infant's physiological parameters, as tactile stimulation aids neurodevelopment without causing stress to the infant's cardiorespiratory system.
Choice C rationale
Handholding alone is insufficient to support bonding and emotional connection. Physiologically stable infants benefit from full body contact during feeding to promote warmth, comfort, and the release of calming hormones like oxytocin.
Choice D rationale
Physiologically stable infants do not experience increased stress during feeding when held. Holding provides comfort and reduces stress, improving the feeding experience and supporting parent-infant bonding and attachment.
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