A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock.
Which of the following statements should the charge nurse make?
Manifestations of shock might not appear until a client loses 20% of their blood volume.
Hemorrhagic shock will cause an increase in a client's serum pH.
The most accurate indication of organ perfusion is a client's urine output.
An infusion of 1 mL of lactated Ringers is given for each 1 mL of blood loss.
The Correct Answer is A
Choice A rationale
Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and
vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.
Choice B rationale
Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.
Choice C rationale
The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator
of organ perfusion.
Choice D rationale
An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.
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Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.
Correct Answer is D
Explanation
Choice A rationale
Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.
Choice B rationale
Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-
circumcision healing.
Choice C rationale
Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,
not a result of urine exposure.
Choice D rationale
Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .