The nurse is monitoring a new client in the fourth stage of labor ...

[APUS57]

The nurse is monitoring a new client in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss?
 
  1. A temperature of 100.4 F
  2. An increased pulse rate of 88 to 102 beats/min
  3. A blood pressure change from 130/88 to 124/80 mm Hg
  4. An increase in the respiratory rate from 18 to 22 breaths/min

Question 2

The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in the:
 
  1. Liver
  2. Tonsils
  3. Spleen
  4. Bone marrow

[cpetit11]

Answer to Question 1

2

Rationale: During the fourth 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 ex-cessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

Answer to Question 2

1

Rationale: The liver contains a large number of macrophages called Kupffer's cells. These cells help filter blood by phagocytizing microorganisms and other foreign particles that pass through the liver. Tonsils, spleen, and bone marrow are incorrect.

[APUS57]

TYSM

[EAN94]

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