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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Placenta previa is a condition where the placenta covers the cervix, which can cause painless bleeding, not severe abdominal pain.
Choice B rationale
Oligohydramnios refers to a condition where there is less amniotic fluid around the baby in the womb. It does not typically cause severe abdominal pain.
Choice C rationale
Abruptio placenta is a serious condition where the placenta detaches from the uterus before the baby is born. It can cause severe abdominal pain and a rigid abdomen, which matches the symptoms described.
Choice D rationale
Chorioamnionitis is an infection of the membranes surrounding the fetus and the amniotic fluid. It typically presents with fever and increased heart rate, not necessarily severe abdominal pain and a rigid abdomen.

A. Praise the client for her actions and offer to discuss ways to decrease consumption even more. B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit. C. Notify child protective services of the client’s illicit drug use and probable child endangerment. D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Correct Answer is A

Explanation

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 38-weeks gestation reports experiencing severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings?

Correct Answer is 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?

Correct Answer is A

Explanation

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 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?

A parent rushes their pre-school age child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

The nurse is instructing the parent of a 10-year-old child newly diagnosed with type 1 diabetes mellitus (DM) on how to administer subcutaneous insulin injections. The parent expresses a fear of needles and is unable to perform the procedure. What intervention should the nurse implement?

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) .

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?