A perinatal nurse receives reports from the nurse aide on four patients who all gave birth within the last 4 hours. Which patient should the nurse assess first?
A.
Blood loss of 850 mL during cesarean birth
B.
Exhausted mother wanting only to rest after childbirth
C.
Pulse consistently ranges from 82 to 90 beats/minute
D.
Systolic blood pressure change from 132 to 110 mm Hg
ANS: D
A drop in blood pressure by 15%, maternal heart rate over 110 beats/minute, or an oxygen saturation less than 95% may indicate a postpartum hemorrhage. The nurse should assess the woman whose blood pressure has changed more than 15%. Blood loss of 850 mL during cesarean birth is not considered excessive. A pulse under 100 beats/minute is normal. A mother may well be exhausted and need to rest, particularly if her birthing experience was difficult or traumatic.
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