A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.
The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.
The nurse should identify the cardiac rhythm as which of the following?

Atrial fibrillation.

Ventricular asystole.

Second-degree heart block.

Sinus tachycardia.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.

Choice B rationale:

Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.

Choice C rationale:

Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.

Choice D rationale:

Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.

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Correct Answer is B

Explanation

Choice A rationale:

Taking ibuprofen during pregnancy is generally not recommended, especially in high doses or for an extended period, as it can increase the risk of complications, including heart defects in the baby. Therefore, advising the client to take 600 milligrams of ibuprofen every 8 hours is not appropriate and potentially harmful during pregnancy.

Choice B rationale:

Having a cesarean birth (C-section) is recommended if there are visible lesions of genital herpes during labor and delivery. This precautionary measure helps prevent the transmission of the herpes simplex virus (HSV) from the mother to the baby, reducing the risk of neonatal herpes infection, which can be severe or even life-threatening.

Choice C rationale:

Testing the baby's cord blood for HSV is not a standard practice. Instead, if there are visible lesions or symptoms of herpes during labor, a C-section is often performed to minimize the risk of transmission. Testing the baby after birth may be done if there are concerns about potential exposure.

Choice D rationale:

Applying a cortisone cream to the lesions is not recommended without medical supervision during pregnancy. Topical corticosteroids, such as cortisone creams, can be absorbed through the skin and may have adverse effects on both the mother and the baby. It is essential to consult a healthcare provider before using any medications or creams during pregnancy to ensure safety for both the mother and the baby.

A. "My child has some swelling around her eyelids and mouth." B. "My child has a temperature of 100.7 degrees Fahrenheit." C. "My child only ate 2 ounces during her last feeding." D. "My child cries when I touch the area where she received the shot." .

Correct Answer is A

Explanation

A) "My child has some swelling around her eyelids and mouth."

In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.

The other findings, while important, are not as immediately concerning:

B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.

C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.

D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.

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A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.The nurse should identify the cardiac rhythm as which of the following?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.
The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.
The nurse should identify the cardiac rhythm as which of the following?