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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A skilled nursing facility is not the best option for this client because it provides long-term care for clients who need 24-hour nursing supervision and assistance with activities of daily living, but not intensive rehabilitation.
Choice B reason: Home care services are not the best option for this client because they provide intermittent care for clients who are able to manage most of their needs at home, but not comprehensive rehabilitation.
Choice C reason: A rehabilitation facility is the best option for this client because it provides short-term care for clients who need intensive physical, occupational, and/or speech therapy to restore or improve their function and independencE.
Choice D reason: A sub-acute care facility is not the best option for this client because it provides intermediate care for clients who need less intensive medical and nursing care than in an acute hospital, but not specialized rehabilitation.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Epidemiology interprets legislation in the community is not a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology does not deal with legal issues, but rather with scientific methods and evidencE.
Choice B reason: Epidemiology relates to the health status of a population is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology measures and monitors the frequency, distribution, and trends of diseases and health indicators in a population.
Choice C reason: Epidemiology analyzes and examines the root causes of health outcomes is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology identifies and investigates the factors and interactions that influence the occurrence and prevention of diseases and health conditions.
Choice D reason: Epidemiology evaluates the effectiveness of nursing interventions is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology designs and conducts studies to assess the impact and outcomes of nursing programs, policies, and practices on population healtH.
Choice E reason: Epidemiology defines the burden of disease and determinants of health is a statement that indicates the importance of epidemiology to the community health nursE. Epidemiology estimates and compares the magnitude and severity of diseases and health problems, as well as their causes and risk factors, in different populations and settings.
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