Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
A client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb).Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?
Correct answer
A
Rationale
The correct answer is A. A blood pressure of 88/40 mm Hg is indicative of hypotension, which is a common sign of hemorrhage due to decreased blood volume. Hypotension results from the body's compensatory mechanisms to maintain perfusion. Options B, C, and D are not specific indicators of hemorrhage. Urinary output of 40 mL/hr is within normal range, moderate rubra lochia is expected in the postpartum period, and a heart rate of 90/min is not necessarily abnormal. It is crucial for the nurse to recognize hypotension as a potential sign of hemorrhage to intervene promptly and prevent further complications.