When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recog-nizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:
a. Absence of cyanosis in the buccal mucosa.
b. Cool, dry skin.
c. Diminished restlessness.
d. Urinary output of at least 30 ml/hr.
D
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A The assessment of the buccal mucosa for cyanosis can be subjective in nature.
B The presence of cool, pale, clammy skin would be an indicative finding asso-ciated with hemorrhagic shock.
C Hemorrhagic shock is associated with lethargy, not restlessness.
D 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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