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 C
Explanation
Choice A rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.
Choice B rationale
Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.
Choice C rationale
The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Choice D rationale
The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .
Correct Answer is B
Explanation
Choice A rationale
Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.
Choice B rationale
Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.
Choice C rationale
Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.
Choice D rationale
Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.