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","F","G"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.
Choice B rationale:
Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.
Choice C rationale:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.
Choice D rationale:
A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.
Choice E rationale:
Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.
Choice F rationale:
A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.
Choice G rationale:
A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.
Choice H rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.
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.