Maternity Nursing: Postpartum Q 5
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?
A. A temperature of 100.4°F.
B. An increase in the pulse from 88 to 102 BPM.
C. An increase in the respiratory rate from 18 to 22 breaths per minute.
D. Blood pressure changes from 130/88 to 124/80 mm Hg.
Correct Answer: B. An increase in the pulse from 88 to 102 BPM.
During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.
Option A: A slight rise in temperature is normal. Patients may also have signs and symptoms of shock, such as confusion, blurry vision, clammy skin, and weakness.
Option C: The respiratory rate has increased slightly. The patient may also have an increased heart rate, an increased respiratory rate, and feeling faint while standing up.
Option D: The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. As the patient continues to lose blood, they may also feel cold, have decreased blood pressure, and may lose consciousness.