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A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago. Which of the following manifestations is a possible indication of postpartum hemorrhage?

A.

Apical pulse 66/min.

B.

Temperature 38.3 C (101° F).

C.

Blood pressure 156/80 mm Hg.

D.

Respiratory rate 32/min.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

An apical pulse of 66/min is within the normal range and not indicative of postpartum hemorrhage, which would typically cause an elevated heart rate due to blood loss.

 

Choice B rationale

 

A temperature of 38.3°C (101°F) could indicate infection or inflammation but is not a direct sign of postpartum hemorrhage, which primarily involves significant blood loss.

 

Choice C rationale

 

Blood pressure of 156/80 mm Hg is elevated but not directly indicative of postpartum hemorrhage, which would typically result in a drop in blood pressure due to loss of blood volume.

 

Choice D rationale

 

A respiratory rate of 32/min is significantly elevated and can be a compensatory response to hypovolemia from postpartum hemorrhage. This response occurs as the body tries to increase oxygen delivery due to blood loss.

 


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

This statement is incorrect because a Papanicolaou test, or Pap smear, is not used for the removal of uterine fibroids. Fibroid removal typically involves surgical procedures like myomectomy.

Choice B rationale

This statement is incorrect because a Pap smear is not used to determine ovulation status. Ovulation can be monitored through methods like basal body temperature tracking or hormone assays.

Choice C rationale

This statement is incorrect because a Pap smear does not detect endometriosis. Endometriosis is usually diagnosed through laparoscopy or imaging studies like ultrasound or MRI.

Choice D rationale

This statement is correct because a Papanicolaou test is specifically designed to detect the presence of cervical cancer and precancerous changes in the cervical cells.

Correct Answer is C

Explanation

Choice A rationale

Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.

Choice B rationale

Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.

Choice C rationale

Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.

Choice D rationale

Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.

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