When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxy-genation is:
1. absence of cyanosis in the buccal mucosa.
2. cool, dry skin.
3. diminished restlessness.
4. urinary output of at least 30 ml/hr.
4
1. Incorrect. The assessment of the buccal mucosa for cyanosis can be subjective.
2. Incorrect. The presence of cool, pale, clammy skin is an indicative finding associated with hemorrhagic shock.
3. Incorrect. Hemorrhagic shock is associated with lethargy, not restlessness.
4. Correct. Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion.
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a. Advances the nasogastric tube while the patient swallows b. Instructs the patient about self-care of the feeding tube c. Eases insertion by icing down the naso-gastric tube d. Measures the length from the patient's nose to the sternum