Nokea
The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation?
Correct Answer: C
Rationale: The correct answer is C because changes in blood pressure may not be an immediate sign of hemorrhage. Hemorrhage can occur rapidly and cause a drop in blood pressure, but it may not be the first sign observed. Vital signs such as blood pressure can fluctuate for various reasons, making it challenging to solely rely on them to identify hemorrhage risk. Elevated blood pressure from prenatal conditions (A) and increased respirations due to labor activity (B) are more likely to be expected and can be explained by those specific factors. Heart rate increasing with the intensity of labor (D) is a common physiological response and may not necessarily indicate hemorrhage.