NCLX Rationals Exam Questions and Answers Latest Update Graded A+
Kernicterus - Answers brain damage that can result from high levels of bilirubin in a baby's blood
resulting in possible problems with vision, teeth, hearing, and intellectual disabilities
Post Op Surgery Report - Answers The OR transport report should contain:
- the type of surgery
- the current vital signs
- the names of the participating surgeons
- the amount of blood loss.
These give the nurse baseline information on the client's condition so that any clinical changes are
understood in the context of what occurred during surgery. The surgeon's names are important so the
nurse has a reference of whom to call if necessary
Required Discharge Referral - Answers When a client spends time in the hospital, the client may still
need a referral to see another provider for follow up after discharge. These situations include when the
client needs help with physical activities or has not attained full health upon dismissal.
oligohydramnios - Answers amniotic fluid volume (AFV) that is less than the minimum expected for
gestational age
Newborn Respiratory Distress - Answers nasal flaring with each breath
substernal and intercostal retractions, agrunting sounds with each breath are signs of respiratory
distress in the infant
postpartum hemorrhage - Answers Risk regardless of delivery method
normal blood loss is around 1,000 mLs (2X normal )
Risk include include a large infant size, uterine atony, lacerations and placental accreta.
Atelectasis - Answers partial or complete collapse of the lung.
synchronized cardioversion - Answers - delivery of a low-energy shock which is timed or synchronized to
be delivered at a specific point in the QRS complex
- delivered at this precise moment to avoid causing or inducing ventricular fibrillation.
CHAIN of SURVIVAL - Answers - Recognition of Cardiac Arrest and Activation of EMS.
, - Immediate High-Quality CPR.
- Rapid Defibrillation.
- Basic and Advanced Emergency Medical Service.
Advanced Life Support and Post-Cardiac Arrest Care.
Recovery.
Non-schockable rhythms - Answers - pulseless electrical activity (PEA)
- asystole
imperforate anus. - Answers a congenital (present from birth) defect in which the opening to the anus is
missing or blocked.
Signs of decreased cardiac output - Answers - decreased peripheral pulses
- exercise intolerance
- cool extremities
- hypotension
- cerebral changes ranging from anxiety/irritability and restlessness to confusion.
base excess - Answers the level of excess (>2) or deficiency (<2) of bicarbonate (a metabolic component)
in the blood. It informs the clinician about the amount of H+ ions that would need to be added to the
blood to bring the pH to 7.35.
Coombs Test - Answers abnormal (positive) direct Coombs test means you have antibodies that act
against your red blood cells.
risk for hyperbilirubinemia - Answers - premature baby has a premature liver and is at risk for
hyperbilirubinemia.
- Bilirubin is excreted in stool, so if an infant doesn't stool frequently then they are at risk for
hyperbilirubinemia
- Bruising increases bilirubin because it is broken down red blood cells.
- Coombs positive means that there was maternal blood mixture of incompatible blood so this baby will
break down red blood cells more and have higher bilirubin.
Folic acid during pregnancy - Answers helps to prevent neural tube defects like spina bifida
Fetal alcohol syndrome (FAS) - Answers - small stature and lack of growth in the affected child
Kernicterus - Answers brain damage that can result from high levels of bilirubin in a baby's blood
resulting in possible problems with vision, teeth, hearing, and intellectual disabilities
Post Op Surgery Report - Answers The OR transport report should contain:
- the type of surgery
- the current vital signs
- the names of the participating surgeons
- the amount of blood loss.
These give the nurse baseline information on the client's condition so that any clinical changes are
understood in the context of what occurred during surgery. The surgeon's names are important so the
nurse has a reference of whom to call if necessary
Required Discharge Referral - Answers When a client spends time in the hospital, the client may still
need a referral to see another provider for follow up after discharge. These situations include when the
client needs help with physical activities or has not attained full health upon dismissal.
oligohydramnios - Answers amniotic fluid volume (AFV) that is less than the minimum expected for
gestational age
Newborn Respiratory Distress - Answers nasal flaring with each breath
substernal and intercostal retractions, agrunting sounds with each breath are signs of respiratory
distress in the infant
postpartum hemorrhage - Answers Risk regardless of delivery method
normal blood loss is around 1,000 mLs (2X normal )
Risk include include a large infant size, uterine atony, lacerations and placental accreta.
Atelectasis - Answers partial or complete collapse of the lung.
synchronized cardioversion - Answers - delivery of a low-energy shock which is timed or synchronized to
be delivered at a specific point in the QRS complex
- delivered at this precise moment to avoid causing or inducing ventricular fibrillation.
CHAIN of SURVIVAL - Answers - Recognition of Cardiac Arrest and Activation of EMS.
, - Immediate High-Quality CPR.
- Rapid Defibrillation.
- Basic and Advanced Emergency Medical Service.
Advanced Life Support and Post-Cardiac Arrest Care.
Recovery.
Non-schockable rhythms - Answers - pulseless electrical activity (PEA)
- asystole
imperforate anus. - Answers a congenital (present from birth) defect in which the opening to the anus is
missing or blocked.
Signs of decreased cardiac output - Answers - decreased peripheral pulses
- exercise intolerance
- cool extremities
- hypotension
- cerebral changes ranging from anxiety/irritability and restlessness to confusion.
base excess - Answers the level of excess (>2) or deficiency (<2) of bicarbonate (a metabolic component)
in the blood. It informs the clinician about the amount of H+ ions that would need to be added to the
blood to bring the pH to 7.35.
Coombs Test - Answers abnormal (positive) direct Coombs test means you have antibodies that act
against your red blood cells.
risk for hyperbilirubinemia - Answers - premature baby has a premature liver and is at risk for
hyperbilirubinemia.
- Bilirubin is excreted in stool, so if an infant doesn't stool frequently then they are at risk for
hyperbilirubinemia
- Bruising increases bilirubin because it is broken down red blood cells.
- Coombs positive means that there was maternal blood mixture of incompatible blood so this baby will
break down red blood cells more and have higher bilirubin.
Folic acid during pregnancy - Answers helps to prevent neural tube defects like spina bifida
Fetal alcohol syndrome (FAS) - Answers - small stature and lack of growth in the affected child
