The nurse is caring for a 3-month-old in respiratory arrest.
Upon assessment, the nurse notes the child is apneic and pulseless.
Which is the appropriate next action to take?
Begin CPR.
Assess the airway.
Auscultate lung sounds.
Obtain a blood pressure.
The Correct Answer is A
Choice A rationale
In pediatric Advanced Life Support, the presence of apnea and pulselessness constitutes a cardiac arrest. The immediate priority is the restoration of circulation and oxygenation through cardiopulmonary resuscitation. Delaying compressions to perform further assessments increases the duration of tissue hypoxia and decreases the chance of a successful resuscitation. Standard protocols dictate that once the absence of a pulse is confirmed within 10 seconds, chest compressions must be initiated immediately to maintain perfusion.
Choice B rationale
Although the airway is a critical component of the ABCs, the scenario explicitly states the infant is already in respiratory arrest and is pulseless. In a pulseless arrest situation, the focus shifts to C-A-B (Circulation, Airway, Breathing) according to current resuscitation guidelines. Opening the airway is important, but it must happen concurrently with or immediately following the initiation of high quality chest compressions to ensure that blood flow to the brain and heart is maintained.
Choice C rationale
Auscultating lung sounds is a diagnostic assessment that is inappropriate during an active cardiac or respiratory arrest. The nurse has already determined the infant is apneic and pulseless, meaning there is no spontaneous ventilation or cardiac output. Taking time to listen to the chest provides no life saving benefit and wastes precious seconds that should be spent on chest compressions. Assessment must be rapid, and interventions must follow immediately when life threatening findings are present.
Choice D rationale
Obtaining a blood pressure is a time consuming task that provides no useful information when a patient is pulseless. A pulseless state by definition means there is no measurable blood pressure. Attempting to use a sphygmomanometer or an automated cuff would result in a significant delay in starting CPR. In emergency situations involving an unconscious and pulseless infant, the nurse must rely on clinical signs of circulation like the brachial pulse rather than equipment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
The formation of ovaries is not a physical change expected during adolescence; rather, it is a developmental process that occurs during fetal gestation. By the time a female reaches puberty, the ovaries are already present and contain a lifetime supply of primordial follicles. Adolescence involves the maturation and activation of these organs under the influence of gonadotropins, not their initial formation. Therefore, this is not a visible adolescent physical change.
Choice B rationale
Menarche, the onset of the first menstrual period, is a hallmark of female adolescent development and typically occurs about two years after the initial appearance of breast buds. It signifies that the hypothalamic-pituitary-gonadal axis has matured enough to induce ovulation and uterine lining shedding. This biological milestone is a key indicator of reproductive maturity. It usually occurs between the ages of 10 and 15, with an average around 12 years.
Choice C rationale
Breast development, or thelarche, is usually the first visible sign of puberty in females. It is driven by increasing levels of estrogen produced by the maturing ovaries. This process involves the enlargement of the areola and the growth of glandular tissue behind the nipple. Thelarche is staged using the Tanner scale to track progression. It is a predictable and expected physical change that occurs early in the adolescent transition.
Choice D rationale
Pubic hair growth, known as adrenarche or pubarche, is a standard physical change in adolescence resulting from increased androgen production from the adrenal glands and ovaries. It typically follows the onset of breast development but can sometimes occur simultaneously. The hair progresses from sparse and downy to thick, curly, and dark. This is an expected finding during a physical exam for a 13-year-old female as she moves through developmental stages.
Choice E rationale
During female adolescence, there is typically an increase in adipose tissue rather than a decrease. Estrogen promotes the deposition of fat in specific areas such as the hips, thighs, and breasts to create the characteristic female body shape. This physiological change is necessary for maintaining the energy stores required for menstruation and future reproductive health. A decrease in adipose tissue would be an abnormal finding unless the client is extremely athletic.
Correct Answer is A
Explanation
Choice A rationale
Postpartum hemorrhage is currently defined by many clinical organizations as a cumulative blood loss ≥ 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. This definition applies regardless of the route of delivery, whether vaginal or cesarean. Monitoring for this threshold allows for rapid intervention to prevent progression to hypovolemic shock. Normal blood loss is typically less than 500 mL for vaginal deliveries.
Choice B rationale
A threshold of 1500 mL is too high for the initial identification of postpartum hemorrhage. While 1500 mL represents a severe or massive hemorrhage that often requires the activation of massive transfusion protocols, waiting for this amount of loss delays life-saving interventions. Clinical recognition should occur much earlier at the 1000 mL mark. Excessive blood loss leads to tachycardia, which is a heart rate > 100 beats per minute, and decreased blood pressure.
Choice C rationale
Historically, 500 mL was the threshold for defining hemorrhage after a vaginal delivery. However, updated clinical guidelines have shifted toward 1000 mL as the universal threshold to improve the accuracy of diagnosis and reduce over-treatment. While 500 mL is still a significant amount of blood loss that requires close observation and fundal massage, it is no longer the primary diagnostic threshold for a formal postpartum hemorrhage diagnosis according to current obstetric standards.
Choice D rationale
A blood loss of 100 mL is considered well within the normal and expected range for the immediate postpartum period. The average blood volume increases by nearly 50 percent during pregnancy to compensate for the expected loss during delivery. A loss of only 100 mL would not trigger any clinical concerns regarding hemorrhage or hemodynamic instability. Nurses must distinguish between normal lochia or minor bleeding and the much larger volumes associated with true hemorrhage.
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