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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.

A. Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale. B. She was assisted to the bathroom where she voided 150 mL of clear yellow urine. C. Lochia rubra is moderate with small clots, no foul odor noted D. The fundus is firm at the umbilicus. E. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. F. There is no pain, redness, or swelling in the calves. G. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. H. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.

Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

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Naxlex Comprehensive Predictor Exams

A woman is in the second stage of labor where 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 expect to perform to assist the healthcare provider?

Correct Answer is B

Explanation

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby Exhibits Which of the following assessment findings requires immediate follow-up by the nurse?

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. What action should the nurse take?

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

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

A client’s maternal serum alpha-fetoprotein level is elevated at 17 weeks. What condition should the nurse identify as the likely cause of this increase?

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

A nurse is caring for a client diagnosed with acute rhinosinusitis. Which of the following instructions should the nurse provide to the client? Select all that apply.