During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?
A Write an incident report about the bruises on the infant.
B Review the labor and delivery record for birth trauma.
C Record the size and location of the areas in the infant's chart.
D Notify the pediatrician of a possible bleeding problem with the infant.
The Correct Answer is C
A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.
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Related Questions
Correct Answer is B
Explanation
Correct Answer: B.
A. Providing a stool softener for constipation might be necessary postpartum but isn't the initial action indicated by the client's current status.
B. Assessing the bladder for distension is crucial because a distended bladder can displace the uterus and impede its ability to contract properly, leading to uterine atony and increased bleeding.
C. Checking the hemoglobin to determine uterine hemorrhage is important but might not be the initial step needed based on the client's condition.
D. Massaging the uterus to decrease atony is a potential intervention, but assessing for bladder distension takes priority in this scenario to prevent uterine displacement.
Correct Answer is C
Explanation
A. Calling the charge nurse might be necessary, but the immediate action after a needlestick injury is to cleanse the affected area to minimize the risk of infection.
B. Observing the appearance of the injection site is important but not the first action following a needlestick injury.
C. Cleaning the finger with soap and water is the initial action to reduce the risk of infection following a needlestick injury.
D. Explaining the occurrence to the client is important but comes after taking care of the nurse's immediate health following a needlestick injury.
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