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 A
Explanation
Choice A rationale
Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.
Choice B rationale
While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.
Choice C rationale
Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.
Choice D rationale
Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.
Correct Answer is C
Explanation
Choice A rationale
Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.
Choice B rationale
Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.
Choice C rationale
Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.
Choice D rationale
Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy.