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 D
Explanation
An Apgar score of 10 at 1 minute after birth indicates that the infant is having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. The Apgar score is a scoring system that evaluates the health of newborns at 1 and 5 minutes after birth based on five criteria: appearance, pulse, grimace, activity, and respiration. Each criterion is scored from 0 to 2, and the total score ranges from 0 to 10. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is concerning.
Choice A is wrong because an Apgar score of 10 at 1 minute does not mean that the infant needs no further testing. The infant should still be assessed again at 5 minutes and monitored for any signs of distress or complications.
Choice B is wrong because an Apgar score of 10 at 1 minute does not indicate an infant in severe distress who needs resuscitation. An Apgar score of 0 to 3 would indicate a concerning condition that may require immediate intervention.
Choice C is wrong because an Apgar score of 10 at 1 minute does not predict a future free of neurologic problems. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia or brain injury; it does not predict individual neonatal mortality or neurologic outcome; and it should not be used for that purpose.
Normal ranges for each criterion are as follows:
- Appearance (color): pink all over (2 points), body pink but extremities blue (1 point), blue, bluish-gray, or pale all over (0 points)
- Pulse (heart rate): greater than 100 beats per minute (2 points), less than 100 beats per minute (1 point), absent (0 points)
- Grimace (response to stimulation): cough or sneeze, cry and withdrawal of foot with stimulation (2 points), facial movement/grimace with stimulation (1 point), absent (0 points)
- Activity (muscle tone): active movement (2 points), limbs flexed (1 point), limp or floppy (0 points)
- Respiration (breathing): good, strong cry (2 points), irregular, weak crying (1 point), absent (0 points)
Correct Answer is A
Explanation
choice A. Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.
Surfactant is a substance that coats the inner surface of the alveoli, the tiny air sacs in the lungs.
It reduces the surface tension of the alveoli and prevents them from collapsing during exhalation.
Premature infants often lack enough surfactant, which leads to respiratory distress syndrome (RDS).
Artificial surfactant is given to these infants to help them breathe more easily. Choice B is wrong because surfactant has nothing to do with sedation.
Sedation is a state of reduced consciousness induced by drugs. Surfactant does not affect the level of consciousness of the infant.
Choice C is wrong because surfactant is not used to reduce episodes of periodic apnea.
Periodic apnea is a condition where the infant stops breathing for a short time, usually due to immature brainstem function.
Surfactant does not affect the brainstem or the control of breathing.
Choice D is wrong because surfactant is not used to fight a possible respiratory tract infection. Surfactant does not have any antibacterial or antiviral properties.
Surfactant is used to treat RDS, which is caused by a lack of surfactant, not by an infection.
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