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?
Apical pulse 66/min.
Temperature 38.3 C (101° F).
Blood pressure 156/80 mm Hg.
Respiratory rate 32/min.
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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Correct Answer is B
Explanation
Choice A rationale
Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.
Choice B rationale
Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.
Choice C rationale
Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.
Choice D rationale
Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .
Correct Answer is B
Explanation
Choice A rationale
Increasing the frequency of feedings from the affected nipple may aggravate nipple soreness, as it doesn't allow the area to recover and heal properly between feedings.
Choice B rationale
Exposing the affected nipple to the air between feedings can help it to dry and heal, reducing soreness. Air exposure can help prevent bacterial growth and keep the nipple area healthy.
Choice C rationale
Applying vitamin E oil to the affected nipple before each feeding is not recommended as it can make the nipple slippery, affecting the baby's latch, and it might not be safe if ingested by the baby.
Choice D rationale
Washing the affected nipple with soap and water before each feeding can strip the natural oils from the skin, leading to further dryness and irritation, which can increase soreness.