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 ["B","C","D","E","F"]
Explanation
A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.
G. "This medication can increase your blood pressure.":
Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
Correct Answer is D
Explanation
Choice A rationale
Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.
Choice B rationale
Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.
Choice C rationale
An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.
Choice D rationale
Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.