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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?

A.

Manifestations of shock might not appear until a client loses 20% of their blood volume.

B.

Hemorrhagic shock will cause an increase in a client's serum pH.

C.

The most accurate indication of organ perfusion is a client's urine output.

D.

An infusion of 1 mL of lactated Ringers is given for each 1 mL of blood loss.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate

Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

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