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 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg

Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg

Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg

Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg

Answer and Explanation

The Correct Answer is D

A.   While the heart rate and respiratory rate are elevated, the blood pressure and temperature are within an acceptable range.
B.   The heart rate and respiratory rate are within normal limits, and the blood pressure is elevated but not as concerning as other options.
C. The temperature and blood pressure are within normal limits, and while the heart rate is slightly elevated, it is not as concerning as other options.
D.   The elevated heart rate, low blood pressure, and elevated temperature may indicate hypovolemic shock, which is of greatest concern given the history of significant estimated blood loss.

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Correct Answer is B

Explanation

A. Moderate bright red lochial flow on postpartum day 14 may indicate excessive bleeding and is not indicative of normal involution.
B. A fundus below the symphysis and nonpalpable suggests a well-contracted uterus, which is indicative of normal involution.
C. An episiotomy that is slightly red and puffy on day 14 may indicate ongoing healing, but it is not a direct measure of uterine involution.
D. Breasts that are firm and tender on postpartum day 14 may indicate engorgement, but they are not directly related to uterine involution.

A. Turn the newborn on his side. B. Use a suction catheter with low negative pressure. C. Suction the mouth with a bulb syringe. D. Suction the nose with a bulb syringe

Correct Answer is C

Explanation

A. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C.Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioningthe nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.

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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 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process?

Correct Answer is B

Explanation

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

Correct Answer is C

Explanation

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