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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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.
Where would acrocyanosis be assessed on a newborn?
- A. feet
- B. mucous membranes
- C. circumoral area
- D. Brow
Correct Answer: A
Rationale: Acrocyanosis is typically observed in the hands and feet of newborns.
Which of the following actions should the nurse take first?
- A. Perform deep suctioning of the newborn's trachea with an endotracheal tube.
- B. Suction the newborn's mouth with a bulb syringe.
- C. Place the newborn in Trendelenburg position.
- D. Administer saline drops into the newborn's nares.
Correct Answer: B
Rationale: Suctioning the mouth with a bulb syringe is the first step to clear mucus and ensure a patent airway.
The mother's temperature is slightly elevated 12 hours after delivery of the baby. What additional assessment would the nurse perform first?
- A. Check a urine specimen for foul odor and cloudiness
- B. Assess skin turgor and condition of the mucous membranes.
- C. Check the appearance and odor of the lochia.
- D. Palpate the fundus for height and firmness
Correct Answer: C
Rationale: Checking lochia for abnormal color or odor can indicate infection, a common cause of elevated temperature.
How many tablets should the nurse administer?
Correct Answer: 2
Rationale: 3 mg -->1.5 mg/tablet = 2 tablets.