PPH may be sudden and result in rapid blood loss.
The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss.
Astute assessment of circulatory status can be done with noninvasive monitoring.
Please match the type of noninvasive assessment that the RN would perform with the appropriate clinical manifestation or body system:.
Pulse oximetry.
Heart sounds.
Arterial pulses
Skin color, temperature, turgor.
Presence or absence of anxiety.
The Correct Answer is E
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.
Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
These are all positive signs of pregnancy, which are definitive and can only be explained by the presence of a fetus.A positive sign of pregnancy is fetal movement palpated by the nurse-midwife.
Choice E is wrong because a positive hCG test is a probable sign of pregnancy, not a positive one.A probable sign of pregnancy is strongly suggestive of pregnancy but could have other causes.A positive hCG test could be caused by medications, tumors, or other conditions that affect the level of hCG in the blood or urine.
Some other probable signs of pregnancy are uterine enlargement, Hegar’s sign (softening of the lower uterine segment), Goodell’s sign (softening of the cervix), Chadwick’s sign (bluish discoloration of the cervix), ballottement (rebound of the fetus when tapped by the examiner’s finger), Braxton Hicks contractions (painless, irregular uterine contractions), and positive pregnancy test.
Some other positive signs of pregnancy are identification of fetal heartbeat, visualization of the fetus by ultrasound or x-ray, and verification of fetal movement by an experienced clinician.
Correct Answer is D
Explanation
Therapeutic management includes the administration of gamma globulin and aspirin. This is because Kawasaki disease causes inflammation in the walls of small to medium-sized blood vessels that carry blood throughout the body and can lead to complications such as coronary artery aneurysms. Gamma globulin is an intravenous immunoglobulin that can reduce the risk of these complications, and aspirin can help lower fever and inflammation.
Choice A is wrong because the child’s fever is usually not responsive to antibiotics within 48 hours. Kawasaki disease is not caused by a bacterial infection, so antibiotics are not effective.
Choice B is wrong because the principal area of involvement is not the joints. Kawasaki disease affects mainly the blood vessels, but it can also cause swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat. Joint pain or swelling may occur, but it is not the main feature of the disease.
Choice C is wrong because aspirin is not contraindicated. Aspirin is part of the standard treatment for Kawasaki disease, along with gamma globulin. However, aspirin should be used with caution and under medical supervision, as it can cause Reye’s syndrome in children with viral infections.
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