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
Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .
Correct Answer is D
Explanation
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.