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 100.4º 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
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.
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