The client is awake and alert, interacting with parents at the bedside.
She has thin, copious mucus from her nose and mouth and a cough.
She took her bottle in 20 minutes, with no issues.
The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic.
The client was placed in a knee-to-chest position, and the rapid response team was called.
What could be the potential cause of the client’s condition?

Seizure activity.

Arrhythmia.

Increased oxygen demand.

Acidosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.

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Correct Answer is C

Explanation

Choice A rationale
Administering oxygen via a facemask is an intervention that can be used if the baby shows signs of distress or if the decelerations do not improve with other interventions. However, it is not the first action that should be taken.
Choice B rationale
Turning off the oxytocin infusion could be an appropriate action if the mother is receiving oxytocin and the baby is showing signs of distress. However, it is not the first action that should be taken.
Choice C rationale
Changing the client’s position is the correct first action for variable decelerations. This can relieve potential cord compression and improve fetal oxygenation.
Choice D rationale
Assessing cervical dilation is an important part of monitoring labor progress, but it is not the first action that should be taken in response to variable decelerations.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

A. Croup

Rationale: Croup is a condition characterized by a barking cough and stridor (a high-pitched breathing sound), often accompanied by noisy breathing. It is a common cause of respiratory distress in children and can present with symptoms similar to those described.

B. Asthma

Rationale: Asthma can present in young children with symptoms such as wheezing, shortness of breath, and rapid breathing. However, diagnosing asthma in very young children can be challenging due to the variability of symptoms and the overlap with other respiratory conditions.

C. Bronchiolitis

Rationale: The child’s symptoms of “fast and noisy breathing” could be indicative of bronchiolitis, a common lung infection in young children. This condition is often preceded by symptoms of a common cold, such as sneezing and a runny nose, which the child had the previous week.

D. Foreign Body Aspiration

Rationale: Foreign body aspiration should be considered in young children who present with sudden onset of respiratory symptoms, including noisy or rapid breathing, particularly if there is a history of coughing or choking.

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Naxlex Comprehensive Predictor Exams

A laboring client has a variable deceleration on the fetal monitor. What is the first action that the nurse should take?

Correct Answer is C

Explanation

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. After reading the history and physical, the nurse suspects the child has dropdown.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

The nurse is providing information to a parent of a six-month old about vaccinations. Which statement made by the parent should the nurse recognize as understanding the information?

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse anticipate performing to assist the healthcare provider?

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse expect?

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse anticipate?

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution. How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

The nurse is evaluating the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?