A straight catheter produced 500 mL of clear yellow urine.
For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia.
Each column must have at least one selection.
Total blood loss of 800 mL
Fundus massaged until firm and at umbilicus
Multiple large clots were expelled
Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air .
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
The findings suggest that the client’s condition has improved.
Choice A rationale
A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.
Choice B rationale
A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.
Choice C rationale
The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.
Choice D rationale
A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Based on the provided information, the following notations require immediate follow-up:
- Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
- Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
- Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.
Correct Answer is ["21"]
Explanation
Step 1 is: Convert 12 hours into minutes. 12 hours × 60 minutes/hour = 720 minutes.
Step 2 is: Calculate the infusion rate. (1000 mL ÷ 720 minutes) × 15 gtt/mL = 20.83 gtt/min. Therefore, the infusion rate should be approximately 21 gtt/min when rounded to the nearest whole number.
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