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 A

Explanation

A. Stabilize the tube by taping it to the infant's cheek. B. Position the infant in a supine position during feedings. C. Aspirate residual fluid from the infant's stomach and discard. D. Microwave the infant's formula to a temperature of 41° C (105.8° F).

Correct Answer is A

Explanation

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).

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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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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?