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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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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