Which of the following findings indicates a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL is experiencing a fluid volume deficit?
900 mL of urine output since the birth
Blood pressure 80/55 mm Hg
Temperature 37.6° C (99.6° F)
Reports of excessive sweating
The Correct Answer is B
Choice A reason: 900 mL urine output over 9 hours (100 mL/hr) is adequate, indicating normal renal perfusion, not fluid volume deficit. Postpartum diuresis occurs as plasma volume normalizes, and this output reflects sufficient hydration. Fluid deficit would reduce urine output (<30 mL/hr), making this finding non-indicative of hypovolemia.
Choice B reason: Blood pressure of 80/55 mm Hg indicates fluid volume deficit, as 1200 mL blood loss causes hypovolemic shock, reducing cardiac output and vascular tone. Hypotension compromises tissue perfusion, risking organ dysfunction. This critical sign requires immediate intervention to restore intravascular volume and prevent maternal collapse, per hemodynamic principles.
Choice C reason: A temperature of 37.6°C (99.6°F) is normal postpartum, reflecting mild inflammatory responses or environmental factors, not fluid volume deficit. Hypovolemia causes tachycardia or hypotension, not fever. Temperature elevation would suggest infection, not blood loss-related hypovolemia, making this finding irrelevant to fluid status, per physiological norms.
Choice D reason: Excessive sweating may occur postpartum due to hormonal shifts or exertion, not necessarily fluid volume deficit. Sweating alone does not confirm hypovolemia without hypotension or tachycardia. Blood loss of 1200 mL requires cardiovascular signs like low blood pressure to diagnose deficit, per hemodynamic and postpartum physiology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Spontaneous rupture of membranes indicates labor progression but does not directly guide oxytocin titration. Oxytocin stimulates uterine contractions, and titration depends on contraction strength and frequency, not membrane status. Rupture enhances labor but lacks specificity for adjusting oxytocin, as it does not reflect myometrial response or contraction adequacy.
Choice B reason: A Bishop score of 2 indicates an unfavorable cervix, suggesting the need for cervical ripening, not immediate oxytocin titration. Oxytocin efficacy depends on contraction patterns, not cervical readiness alone. The score assesses dilation and effacement, but titration requires monitoring uterine response, making this finding irrelevant for adjusting the infusion rate.
Choice C reason: Mild contractions indicate inadequate uterine response to 1 milliunit/min of oxytocin, warranting titration to 2 milliunits/min to achieve an expected labor pattern. Oxytocin stimulates myometrial contractions, and mild intensity suggests insufficient stimulation. Increasing the dose enhances contraction strength and frequency, aligning with labor induction protocols to promote effective labor.
Choice D reason: Contractions every 1 minute indicate hyperstimulation, risking fetal distress due to reduced placental perfusion. Oxytocin titration aims for contractions every 2-3 minutes. This frequency suggests excessive uterine activity, requiring a decrease or pause in oxytocin, not an increase, to prevent hypoxia and ensure fetal safety during labor.
Correct Answer is A
Explanation
Choice A reason: A change in deep tendon reflexes from 4+ (hyperreflexic) to 2+ (normal) indicates magnesium sulfate’s therapeutic effect in preeclampsia, as it reduces neuronal excitability, preventing seizures. Magnesium stabilizes nerve membranes, lowering seizure risk by modulating calcium channels, aligning with its anticonvulsant role in preeclampsia management.
Choice B reason: A fetal heart rate increase from 150/min to 166/min is not a direct indicator of magnesium sulfate’s effectiveness. Magnesium primarily prevents maternal seizures, not fetal heart rate changes. This increase may reflect fetal stress or normal variation, unrelated to magnesium’s neurological stabilization in preeclampsia treatment.
Choice C reason: Minimal fetal heart rate variability suggests fetal compromise, not magnesium sulfate’s desired effect. Magnesium aims to prevent maternal seizures without significantly altering fetal heart patterns. Reduced variability may indicate hypoxia, requiring separate intervention, as it does not reflect the drug’s therapeutic goal of maternal neurological stabilization.
Choice D reason: Urinary output of 20 mL/hr indicates potential magnesium toxicity or renal impairment, not therapeutic effectiveness. Magnesium sulfate requires adequate renal excretion to avoid toxicity, and output below 30 mL/hr suggests accumulation, risking respiratory depression or cardiac effects, contrary to the drug’s intended anticonvulsant action in preeclampsia.
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