A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago.
The birth was vaginal and the estimated blood loss (EBL) was approximately 1500 ml. When assessing the woman's vital signs, the nurse would be concerned to see:
Temperature 36.8° C, heart rate 60, respirations 18, blood pressure 140/90.
Temperature 38° C, heart rate 80, respirations 16, blood pressure 110/80.
Temperature 37.4° C, heart rate 88, respirations 36, blood pressure 126/68.
Temperature 37.9° C, heart rate 120, respirations 20, blood pressure 90/50. —
The Correct Answer is D
Choice A rationale
A temperature of 36.8° C (normal is 36.2° C to 38° C), a heart rate of 60 beats per minute (normal 60–100 bpm), respirations of 18 (normal 12–20 breaths/min), and a blood pressure of 140/90 mmHg are all within or near the normal postpartum range, showing an elevated but common blood pressure post-birth.
Choice B rationale
A temperature of 38° C is the upper limit of normal; a heart rate of 80, respirations of 16, and blood pressure of 110/80 mmHg are generally within normal limits. The slight temperature elevation is common due to exertion and mild dehydration but is not a sign of major concern 1 hour after birth.
Choice C rationale
A temperature of 37.4° C, heart rate of 88, and blood pressure of 126/68 mmHg are generally within normal postpartum ranges. However, respirations of 36 breaths/min (normal 12–20 breaths/min) indicate tachypnea, which is an abnormal finding and requires immediate investigation for conditions like pulmonary embolism or shock.
Choice D rationale
A heart rate of 120 beats per minute (tachycardia) and a blood pressure of 90/50 mmHg (hypotension), especially following an estimated blood loss (EBL) of 1500 ml (a major postpartum hemorrhage is >1000 ml), are critical signs of impending or actual hypovolemic shock due to significant blood volume deficit. Immediate intervention is required. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Phototherapy utilizes ultraviolet light to convert unconjugated bilirubin (a neurotoxic substance) into water-soluble photoisomers that can be excreted in bile and urine, thus reducing hyperbilirubinemia. The intense light, specifically the blue spectrum (460-490 nm), can cause retinal damage as the immature retina absorbs the light energy. Eye shields protect the delicate retina, preventing potential long-term visual impairment from light exposure.
Choice B rationale
Frequent position changes are crucial, ideally every 2 to 3 hours, not every 4 hours, to maximize the skin surface area exposed to the phototherapy lights. This ensures maximal photo-oxidation of the unconjugated bilirubin throughout the body, accelerating its conversion and excretion. Delayed turning reduces the therapeutic effect of the light treatment.
Choice C rationale
The newborn needs adequate fluid intake, often requiring increased frequency of breastfeeding or formula, to compensate for insensible water loss and diarrhea (a common side effect) caused by phototherapy. Increased fluid volume aids in the renal and fecal excretion of the bilirubin photoisomers, facilitating the clearance of the hyperbilirubinemia.
Choice D rationale
Oil-based lotions and ointments are contraindicated during phototherapy because they can absorb the ultraviolet light and cause an increased heat build-up. This can lead to skin burns and thermal injury. Furthermore, applying oil can block the skin's surface area, interfering with the penetration of light necessary for bilirubin photo-oxidation.
Correct Answer is A
Explanation
Choice A rationale
The Apgar score is a rapid assessment of the newborn's immediate transition to extrauterine life. It evaluates five signs: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. The initial assessments are standardized at 1 and 5 minutes after birth to track improvement or deterioration.
Choice B rationale
The Apgar score is performed at 1 and 5 minutes as a baseline and assessment of immediate transition. It is repeated at 10 minutes only if the 5-minute score is 6 or less. Assessing it every 15 minutes during the first hour is not the standardized practice for this specific tool.
Choice C rationale
Although the obstetrician or nurse initially performs the Apgar, it is a timed assessment and is standardly performed by the nurse or healthcare provider at least twice (at 1 and 5 minutes). The nurse's role is to ensure the 5-minute score is recorded and to continue monitoring.
Choice D rationale
The Apgar assessment is a routine, standardized component of the initial newborn assessment for all infants. It serves as an objective method to determine the need for immediate resuscitation (if 1-minute score is low) or continued close observation, not only for obvious distress. —.
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