Nokea
skin color becomes ashen
- A. Woman states that she feels 'weak, lightheaded or nauseous'
- B. BP declines
- C. elevated temperature
- D. pulse rate declines
Correct Answer: A,B,C
Rationale: Ashen skin, weakness/lightheadedness/nausea, and declining BP are signs of hypovolemic shock due to blood loss.
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How many mL should the nurse administer?
Correct Answer: 1.5
Rationale: 15 mg -->10 mg/mL = 1.5 mL.
Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min
- B. 48/min
- C. 100/min
- D. 110/min
Correct Answer: B
Rationale: A newborn's normal respiratory rate is 30-60 breaths per minute; 48/min is within this range.
Which of the following findings should alert the nurse to the possibility of a postpartum complication?
- A. Fundus at umbilicus level
- B. Urinary output 3,000 mL/12 hr
- C. Chills shortly following delivery
- D. Heart rate 110/min
Correct Answer: D
Rationale: An elevated heart rate of 110/min may indicate infection or hemorrhage, requiring further assessment.
Which of the following suggestions should the nurse make? (Select all that apply.)
- A. Carry the newborn in a front or back pack.
- B. Allow the newborn to continue crying until she falls asleep.
- C. Swaddle the newborn in a receiving blanket.
- D. Keep the newborn in the center of a large crib.
- E. Take the newborn for a ride in the car.
Correct Answer: A,C,E
Rationale: Carrying in a pack, swaddling, and car rides provide comfort and security, soothing the newborn. Allowing prolonged crying or placing in a large crib does not promote calming.
Six to twelve hours after the vaginal delivery of a single infant and placenta, the uterine fundus should be palpable at or below the level of
- A. pubic symphisis
- B. epigastrum
- C. umbilicus
- D. it should not be palpable at this stage
Correct Answer: C
Rationale: The fundus is typically at or below the umbilicus 6-12 hours post-delivery as part of normal uterine involution.