How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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?

A.

Seizure activity.

B.

Arrhythmia.

C.

Increased oxygen demand.

D.

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. 
 
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Choice A rationale

Preparing a vacuum is not the first action to take when the fetal head retracts against the perineum during the second stage of labor.

Choice B rationale

Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.

Choice C rationale

Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.

Choice D rationale

Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.

Correct Answer is D

Explanation

The correct answer is **d. Monitor the infant for response to auditory stimuli**.

Choice A rationale:

Drawing an antibiotic trough level within 3 days is not a necessary action after a 14-day antibiotic treatment for bacterial meningitis in an infant. Trough levels are typically monitored during the course of treatment to ensure appropriate dosing, not after completion of therapy.

Choice B rationale:

Administering antipyretic medication continuously is not recommended after the completion of antibiotic treatment for bacterial meningitis. Fever is a common symptom during the acute phase of the illness, and the need for antipyretics should decrease as the infection is resolved.

Choice C rationale:

Continuing strict monitoring of daily wet diapers for 1 week is not a necessary action after the completion of antibiotic treatment for bacterial meningitis. Monitoring fluid intake and output is important during the acute phase of the illness, but not necessarily after the infant has completed the full course of antibiotics.

Choice D rationale:

Monitoring the infant for response to auditory stimuli is an important action to include when preparing the family for discharge after a 14-day antibiotic treatment for bacterial meningitis. Hearing loss is a potential complication of bacterial meningitis, and the infant should be evaluated for any hearing impairment before being discharged from the hospital.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register