Included in the definition of tachysystole is:
Contraction duration of less than 40 seconds.
Contraction frequency of greater than 5 in 10 minutes.
Contraction intensity of less than 80 mm Hg.
Resting tone of less than 18 mm Hg.
The Correct Answer is B
Choice A rationale
Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on frequency, not duration, of contractions over a specific time frame.
Choice B rationale
Contraction frequency of more than 5 in 10 minutes defines tachysystole. This frequency indicates excessive uterine activity, requiring intervention to prevent fetal distress.
Choice C rationale
Contraction intensity less than 80 mm Hg does not define tachysystole. Intensity relates to contraction strength, but tachysystole is about frequency exceeding the normal range.
Choice D rationale
Resting tone less than 18 mm Hg isn't part of tachysystole's definition. Tachysystole pertains to contraction frequency, not resting tone, which measures uterine relaxation between contractions.
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Correct Answer is D
Explanation
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.
Correct Answer is B
Explanation
Choice A rationale
Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.
Choice B rationale
Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.
Choice C rationale
Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.
Choice D rationale
Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.