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.

Suction the oral and nasal passages.

Give oxygen by positive pressure.

Stimulate the infant to cry.

Answer and Explanation

The Correct Answer is B

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

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Correct Answer is B

Explanation

Choice A rationale:

Planning to have the client lay down for 1 hour after meals is not an appropriate intervention for a client with COPD. It may increase the risk of aspiration and worsen their breathing difficulties.

Choice C rationale:

Encouraging the client to use the upper chest for respiration is not the best approach for a client with COPD. Pursed-lip breathing helps improve oxygen exchange and decreases air trapping, which is more effective in managing COPD.

Choice D rationale:

Restricting the client's fluid intake to less than 1 Vday is not a suitable intervention for a client with COPD. Dehydration can lead to thicker mucus, making it harder to breathe

A. The client's financial resources B. The client's level of family support C. The client's access to transportation D. The client's ability to prepare meals

Correct Answer is D

Explanation

Choice A reason: The client's financial resources are not the most important factor for the nurse to consider because Meals-on-Wheels is a program that provides low-cost or free meals to seniors and people with disabilities who are unable to cook or shop for themselves.

Choice B reason: The client's level of family support is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that aims to reduce social isolation and improve nutrition for homebound clients, regardless of their family situation.

Choice C reason: The client's access to transportation is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that delivers meals directly to the client's home, eliminating the need for transportation.

Choice D reason: The client's ability to prepare meals is the most important factor for the nurse to consider because Meals-on-Wheels is a program that caters to clients who have difficulty or inability to cook or shop for themselves due to physical, mental, or environmental limitations.

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A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

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Naxlex Comprehensive Predictor Exams

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