Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is collecting data on a client who is 6 hours postpartum following an uncomplicated vaginal delivery. Which finding is the priority to report to the registered nurse immediately?

  1. A gradual increase in heart rate from 78 to 112 beats/minute and a blood pressure decrease from 122/76 to 104/62 mm Hg.Cevap
  2. B
    Saturation of one perineal pad over a three-hour period with dark red lochia.
  3. C
    Intense uterine cramping that worsens while the client is breastfeeding the newborn.
  4. D
    An oral temperature of 100.1°F (37.8°C) accompanied by mild diaphoresis.

Cevap

The finding that requires immediate reporting is the gradual increase in heart rate accompanied by a decrease in blood pressure.
The correct answer identifies subtle but progressive vital sign changes (tachycardia and mild hypotension), which are early, critical indicators of compensatory hypovolemic shock. In a postpartum client, this strongly suggests an undetected hemorrhage. The PN must prioritize this finding and report it immediately to the RN for further assessment and medical intervention, as it directly impacts the client's circulation (ABCs).

Adım Adım Çözüm

1
Analyze the client's current clinical status and the timeframe.
The client is 6 hours postpartum, a high-risk period for hemorrhage and physiological fluid shifts.
Establishing the timeframe helps differentiate between normal expected adaptations and acute complications.
2
Evaluate each data finding against expected normal postpartum physiological adaptations.
Saturating one pad in three hours, afterpains during breastfeeding, and a slight temperature elevation up to 100.4°F (38.0°C) are all normal, expected findings.
Normal findings reflect expected healing and hormonal changes, and they do not require immediate urgent reporting to the RN.
3
Identify any findings that compromise Airway, Breathing, or Circulation (ABCs).
The steadily rising heart rate and falling blood pressure indicate a serious circulation issue, specifically compensatory hypovolemia.
Prioritization questions require focusing on ABCs; early signs of shock must be escalated immediately to prevent severe cardiovascular collapse.

Anahtar Kavram

Early recognition of hypovolemic shock in the postpartum period
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru