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 A

Explanation

Choice A rationale

Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.

Choice B rationale

Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.

Choice C rationale

While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.

Choice D rationale

Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.

A. Assess for bladder distention. B. Listen for bowel sounds. C. Document the observation. D. Check the scrotum for testicular descent.

Correct Answer is C

Explanation

Choice A rationale
While assessing for bladder distention is important in general urinary assessment, it is not directly related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice B rationale
Listening for bowel sounds is a part of the general abdominal assessment. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice C rationale
Documenting the observation is the correct action. The nurse has observed that the infant voids a urinary stream from the ventral surface of the penis. This could indicate a condition such as hypospadias, where the urethral opening is on the underside of the penis. This is an important finding that should be documented and reported.
Choice D rationale
Checking the scrotum for testicular descent is part of the general assessment of the male genitalia. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

Correct Answer is C

Explanation

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?

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.

The nurse is educating parents on how to prevent recurrent otitis media in their infant. What advice should the nurse give?

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD. Which statement(s) made by the caregiver demonstrates an understanding?

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 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.