A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?
Turn the infant onto the right side.
Give oxygen by positive pressure
Suction the oral and nasal passages.
Stimulate the infant to cry.
The Correct Answer is C
The correct answer is choice C. Suction the oral and nasal passages.
Choice A rationale:
Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.
Choice B rationale:
Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.
Choice C rationale:
Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.
Choice D rationale:
Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.
The other options are not correct because:
A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.
C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.
D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.
Correct Answer is B
Explanation
The correct answer is **b. Oral feeding of a two-year-old child after application of a hip spica cast.**
Choice A rationale:
Participation in staff rounds to record notes regarding client goals is not an appropriate task to delegate to a UAP. This task requires clinical assessment, judgment, and documentation skills that are within the scope of practice of a licensed practical nurse (PN), but not a UAP.
Choice B rationale:
Oral feeding of a two-year-old child after application of a hip spica cast is an appropriate task that the PN can delegate to a UAP. Feeding a stable patient is a routine task that does not require advanced nursing skills or clinical judgment. As long as the child is not at high risk for complications, this task can be safely delegated to a UAP with proper training and supervision.
Choice C rationale:
Evaluation of a client's incisional pain following narcotic administration is not an appropriate task to delegate to a UAP. This task requires clinical assessment, evaluation of medication effects, and critical thinking skills that are within the scope of practice of a PN, but not a UAP.
Choice D rationale:
Assessment of the placement and patency of a nasogastric feeding tube is not an appropriate task to delegate to a UAP. This task requires specialized nursing skills and clinical judgment to ensure the safety and effectiveness of the feeding tube. It is within the scope of practice of a PN, but not a UAP.
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