A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
Select one:

Contact the physician, as it indicates early DIC.

Contact the physician, as it is a first sign of postpartum eclampsia.

Document the finding as it is a normal finding at this time.

Obtain an order for a CBC, as it suggests postpartum anemia.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Contact the physician, as it indicates early DIC. This is an incorrect answer that confuses a low pulse rate with a high pulse rate. DIC stands for disseminated intravascular coagulation, which is a life-threatening condition where abnormal clotting and bleeding occur simultaneously in the body. DIC can occur as a complication of postpartum hemorrhage, infection, or placental abruption. DIC can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

Choice B Reason: Contact the physician, as it is a first sign of postpartum eclampsia. This is an incorrect answer that misinterprets a low pulse rate as a sign of hypertension. Postpartum eclampsia is a condition where seizures occur in a woman who has preeclampsia or eclampsia after delivery. Preeclampsia and eclampsia are characterized by high blood pressure and proteinuria in pregnancy. Postpartum eclampsia can cause hypertension (high blood pressure), not hypotension (low blood pressure).

Choice C Reason: Document the finding as it is a normal finding at this time. This is because a pulse rate of 60 beats per minute is within the normal range for an adult and may reﬂect a physiological adaptation to the postpartum period. During pregnancy, the maternal blood volume and cardiac output increase, which can elevate the pulse rate. After delivery, these parameters gradually return to pre-pregnancy levels, which can lower the pulse rate.

Choice D Reason: Obtain an order for a CBC, as it suggests postpartum anemia. This is an incorrect answer that assumes that a low pulse rate is caused by anemia. Anemia is a condition where the red blood cell count or hemoglobin level is lower than normal, which can impair oxygen delivery to the tissues. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy. Anemia can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

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Correct Answer is A

Explanation

Choice A Reason: Episodes of hypoglycemia and hyperglycemia. This is because episodes of hypoglycemia and hyperglycemia are common complications of diabetes during pregnancy, which can aﬀect both the mother and the fetus. Hypoglycemia is a condition where the blood glucose level drops below the normal range, which can cause symptoms such as sweating, trembling, hunger, confusion, or loss of consciousness. Hyperglycemia is a condition where the blood glucose level rises above the normal range, which can cause symptoms such as thirst, polyuria, fatigue, blurred vision, or ketoacidosis. Diabetes during pregnancy requires careful monitoring and management of blood glucose levels to prevent adverse outcomes such as fetal macrosomia, congenital anomalies, stillbirth, or neonatal hypoglycemia.

Choice B Reason: Postpartum hemorrhage. This is an incorrect answer that refers to a diﬀerent complication that may occur after delivery, not during pregnancy. Postpartum hemorrhage is excessive bleeding from the uterus or genital tract after delivery, which can cause hypovolemic shock, anemia, or death. Postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.

Choice C Reason: Cerebrovascular accident (CVA). This is an incorrect answer that indicates a rare and severe complication that may occur during or after pregnancy, not specifically related to diabetes. CVA is also known as stroke, which is an interruption of blood ﬂow to the brain due to ischemia or hemorrhage, which can cause neurological deficits or death. CVA can be caused by hypertension, preeclampsia-eclampsia, thrombophilia, or vascular malformations.

Choice D Reason: Acute vasospasm. This is an incorrect answer that suggests a diﬀerent condition that may occur during pregnancy, not associated with diabetes. Acute vasospasm is also known as Raynaud's phenomenon, which is a disorder of blood vessels that causes them to narrow and reduce blood ﬂow to the extremities in response to cold or stress, which can cause pain, numbness, or color changes. Acute vasospasm can be triggered by smoking, medications, or autoimmune diseases.

A. Moderate amounts of deep red lochia. B. Sweating while afebrile. C. Voiding 350 mL of blood-tinged urine. D. Heart rate of 115 beats/minute.

Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

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A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

If a woman has a pre-existing condition of diabetes, the nurse knows that she would be at risk for what symptom(s) during her pregnancy? Select one:

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
Select one: