A nurse observes circumoral cyanosis in an infant who is choking.
Which of the following actions should the nurse take?
Deliver back blows with the infant face down over the rescuer's arm.
Move the infant into an upright position and suction the airway with a bulb syringe.
Perform a head tilt and a chin lift and then give two rescue breaths.
Place the infant in a side-lying position and perform abdominal thrusts.
The Correct Answer is A
Choice A rationale
Delivering back blows with the infant face down over the rescuer's arm is the appropriate first aid response to an infant choking. This method uses gravity and force to help dislodge the object from the infant's airway, providing a swift and effective means to clear the obstruction and prevent further complications from lack of oxygen.
Choice B rationale
Moving the infant into an upright position and suctioning the airway with a bulb syringe is not suitable for an acute choking situation. Suctioning is more appropriate for clearing mucus or fluids, not solid objects blocking the airway, and it could delay necessary intervention.
Choice C rationale
Performing a head tilt and a chin lift with rescue breaths is typically used in CPR for unresponsive infants, not choking. Administering rescue breaths on a choking infant may force the object further into the airway, worsening the blockage.
Choice D rationale
Placing the infant in a side-lying position and performing abdominal thrusts is not recommended for infants under one year old. Abdominal thrusts can cause injury to the internal organs. The appropriate technique is back blows and chest thrusts for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition: Hypoglycemia.
2 actions:
Administer intravenous dextrose as prescribed,
Encourage breastfeeding to promote glucose stability.
2 parameters:
Blood glucose levels,
Muscle tone and reflexes.
Rationale for correct condition: The newborn's blood glucose level is critically low at 35 mg/dL, indicating hypoglycemia. Symptoms like jitteriness, decreased muscle tone, poor feeding, and irritability align with neonatal hypoglycemia. Hypoglycemia is common in newborns, especially with the stress of delivery. Early identification and treatment are crucial to prevent complications. The presence of hypoglycemia requires immediate intervention to stabilize the newborn's condition.
Rationale for actions: Administering intravenous dextrose is essential to quickly raise the newborn's blood glucose level. Dextrose provides a rapid source of glucose, addressing the immediate hypoglycemia. Encouraging breastfeeding promotes regular feeding, helping to maintain stable blood glucose levels over time. Frequent feeding supports glucose stability. Administering phototherapy treats hyperbilirubinemia, not hypoglycemia. Administering calcium gluconate addresses hypocalcemia, which is secondary here. Gastric lavage is unnecessary for feeding intolerance in this context.
Rationale for parameters: Monitoring blood glucose levels is critical to ensure the newborn's glucose levels remain stable. Frequent checks guide the effectiveness of treatment. Muscle tone and reflexes assess neurological responses and improvement with treatment. Changes can indicate recovery from hypoglycemia. Serum bilirubin levels are related to jaundice. Oxygen saturation is stable and unrelated to hypoglycemia. Serum calcium levels monitor hypocalcemia, not directly hypoglycemia.
Rationale for incorrect conditions: Neonatal Abstinence Syndrome presents with withdrawal symptoms, not primarily hypoglycemia. Neonatal sepsis would show signs of infection and systemic instability. Hyperbilirubinemia focuses on elevated bilirubin and jaundice.
Correct Answer is A
Explanation
Choice A rationale
The radial pulse is palpated at the wrist, on the thumb side. This is the most common site for checking pulse in a school-age child.
Choice B rationale
The inner side of the elbow is where the brachial pulse is palpated, commonly used for blood pressure measurements.
Choice C rationale
The neck is where the carotid pulse is palpated, generally used in emergencies when the radial pulse is not palpable.
Choice D rationale
The upper arm is where the brachial artery is located but is not used to measure the radial pulse.
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