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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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Correct Answer is C

Explanation

Choice A rationale

Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.

Choice B rationale

Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.

Choice C rationale

Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.

Choice D rationale

Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .

Correct Answer is A

Explanation

Choice A rationale

Deep-vein thrombosis (DVT) is a contraindication for diaphragm use due to the increased risk of thromboembolic events with estrogen-based contraceptives.

Choice B rationale

Tobacco use, although a risk factor for cardiovascular disease, is not a direct contraindication for diaphragm use, which is a non-hormonal contraceptive method.

Choice C rationale

Recurrent urinary tract infections are a contraindication for diaphragm use due to the risk of infection exacerbation from device insertion.

Choice D rationale

History of positive group B streptococcus B-hemolytic is not a contraindication for diaphragm use; it typically relates to pregnancy and neonatal infection risk.

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