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What does the nurse recognize as the possible cause of these signs and symptoms?
- A. Dehydration
- B. Hypovolemic shock
- C. Endometritis
- D. Cystitis
Correct Answer: C
Rationale: Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.
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What is the most likely cause?
- A. Pulmonary embolism
- B. Hypertension
- C. Allergy
- D. Blood clotting disorder
Correct Answer: C
Rationale: Anaphylactic shock is caused by allergic responses to drugs administered.
What does the nurse suspect from these symptoms?
- A. Phlebitis
- B. Puerperal infection
- C. Late postpartum hemorrhage
- D. Mastitis
Correct Answer: A
Rationale: The complaints related to the leg, such as redness and pain, are indicative of phlebitis. The other signs are normal in the postpartum patient.
What is the first sign of hypovolemic shock from postpartum hemorrhage?
- A. Cold, clammy skin
- B. Tachycardia
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: Tachycardia is usually the first sign of inadequate blood volume.
What nursing action is the most appropriate to prevent thrombus formation?
- A. Have the woman sit in a chair for meals.
- B. Monitor vital signs every 4 hours and report any changes.
- C. Tell the woman to remain in bed with her legs elevated.
- D. Assist the woman with ambulation for short periods of time.
Correct Answer: D
Rationale: Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.
A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
- A. Provision of IV fluids
- B. Placement of an indwelling Foley catheter
- C. Assessment of oxygen saturation
- D. Administration of anticoagulants
- E. Blood transfusion
Correct Answer: A,B,C,E
Rationale: Management of hypovolemic shock includes stopping blood loss, giving IV fluids, placing a Foley catheter, assessing oxygen saturation, and giving blood transfusions. Anticoagulants are not used.