Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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:.
A. Pulse oximetry.
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
B. Heart sounds.
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.
C. Arterial pulses
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.
D. Skin color, temperature, turgor.
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.
E. Presence or absence of anxiety.
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
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
Which data would be included in a health history? (Select all that apply.).
A. Review of systems.
Choice A is correct because review of systems is a systematic method of collecting data on all body systems.
B. Physical assessment.
Choice B is wrong because physical assessment is not part of the health history, but a separate process of examining the patient’s body systems.
C. Sexual history.
Choice C is correct because sexual history is an important aspect of the patient’s health that may affect their risk for sexually transmitted infections, reproductive health, and psychosocial well-being.
D. Height, Weight, BMI data.
Choice D is correct because height, weight, BMI data are part of the biographical data that provide a baseline for comparing the patient’s characteristics to established norms for physical and emotional health.
E. Diet and nutritional intake.
Choice E is correct because diet and nutritional intake are relevant factors that influence the patient’s health status and may indicate potential problems such as malnutrition, obesity, or eating disorders.
F. Family medical history.
Choice F is correct because family medical history provides information about the patient’s genetic risk for certain diseases and conditions that may affect their current or future health.
Full Explanation
A health history is a holistic assessment of all factors affecting a patient’s health status, including information about social, cultural, familial, and economic aspects of the patient’s life as well as any other component of the patient’s life style that affects health and well-being.
Choice B is wrong because physical assessment is not part of the health history, but a separate process of examining the patient’s body systems.
Choice A is correct because review of systems is a systematic method of collecting data on all body systems.
Choice C is correct because sexual history is an important aspect of the patient’s health that may affect their risk for sexually transmitted infections, reproductive health, and psychosocial well-being.
Choice D is correct because height, weight, BMI data are part of the biographical data that provide a baseline for comparing the patient’s characteristics to established norms for physical and emotional health.
Choice E is correct because diet and nutritional intake are relevant factors that influence the patient’s health status and may indicate potential problems such as malnutrition, obesity, or eating disorders.
Choice F is correct because family medical history provides information about the patient’s genetic risk for certain diseases and conditions that may affect their current or future health.
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:.
A. Suffering from sleep or wakeful apnea.
Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.
B. Experiencing severe swings in blood pressure.
Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.
C. Trying to maintain a neutral thermal environment.
Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.
D. Breathing in a respiratory pattern common to premature infants.
This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.
Full Explanation
This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.
Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.
Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.
Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.
Normal ranges for respiratory rate in premature infants are 40 to 60 breaths per minute. Normal ranges for oxygen saturation in premature infants are 88% to 92%.
Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):.
A. Pitocin.
Pitocin is a medicationused to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
B. Methergine.
Methergine is a medication used to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
C. Terbutaline.
Choice C is wrong because Terbutaline is a medication that relaxes the uterus and is used to stop preterm labor, not PPH.
D. Hemabate.
Choice D is wrong because Hemabate is a brand name for carboprost, which is a prostaglandin that can be used for PPH, but it has more side effects and contraindications than Pitocin or Methergine.
E. Magnesium sulfate.
Choice E is wrong because Magnesium sulfate is a medication that prevents seizures in women with preeclampsia or eclampsia, not PPH.
Full Explanation
Pitocin and Methergine are both medications used to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
Choice C is wrong because Terbutaline is a medication that relaxes the uterus and is used to stop preterm labor, not PPH.
Choice D is wrong because Hemabate is a brand name for carboprost, which is a prostaglandin that can be used for PPH, but it has more side effects and contraindications than Pitocin or Methergine.
Choice E is wrong because Magnesium sulfate is a medication that prevents seizures in women with preeclampsia or eclampsia, not PPH.