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 C

Explanation

Choice A reason: Mitigation is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on reducing or eliminating risks and vulnerabilities before a disaster occurs, such as building levees or dams, enforcing zoning codes, or implementing insurance policies.

Choice B reason: Security is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is not a level of the framework, but rather a cross-cutting function that supports all levels by ensuring the protection of people, property, and information from threats or hazards.

Choice C reason: Preparedness is the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on enhancing the readiness and capabilities of individuals, organizations, and communities to respond to and recover from a disaster, such as developing plans, conducting trainings, or providing education.

Choice D reason: Response phase is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on delivering immediate assistance and resources to save lives, protect property, and meet basic needs during and after a disaster, such as activating emergency operations centers, deploying teams, or providing shelter.

A. Hypertension B. Tinnitus C. Hypotension D. Tachycardia

Correct Answer is A

Explanation

Choice A reason: Hypertension is a manifestation of increased intracranial pressure because it is part of the Cushing's triad, which is a set of signs that indicate increased intracranial pressure and impaired cerebral perfusion. The other signs of Cushing's triad are bradycardia and irregular respirations.

Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure because it is a symptom of hearing loss, ear infection, or ear damage, not increased intracranial pressurE. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors such as exposure to loud noise, aging, or medication side effects.

Choice C reason: Hypotension is not a manifestation of increased intracranial pressure because it is a sign of decreased blood pressure, not increased intracranial pressurE. Hypotension can be caused by various factors such as dehydration, blood loss, or shock.

Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure because it is a sign of increased heart rate, not increased intracranial pressurE. Tachycardia can be caused by various factors such as anxiety, fever, or pain.

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