NCLEX-PN

Category - Reduction of Risk

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A nurse is caring for a client who delivered a baby girl 8 hours ago through a vaginal birth. Which of the following findings during the assessment prompts the nurse to contact the RN or physician immediately?

Blood pressure = 80/60
Heart rate = 95 beats/minute
Oral temperature = 100.6^OF
Firm fundus

Explanation

Answer: A - A decreasing blood pressure or a heart rate greater than 100 beats per minute should prompt the nurse to contact the physician, as it can be an early sign of hemorrhage. A slight increase in temperature less than 24 hours of child birth is a common manifestation and does not indicate an infection. A firm fundus is a good finding after birth.

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