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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Encouraging the mother to use a one-piece pacifier is the appropriate action as it reduces the risk of choking or ingestion of small parts and is safer for the infant.
B. Observing the infant for difficulty in sucking is important, but addressing the safety of the pacifier takes precedence.
C. Informing the mother about potential dental problems associated with pacifier use might be relevant but doesn't address the immediate safety concern of the makeshift pacifier.
D. Complimenting the mother for meeting her infant's needs doesn't address the potential safety risks associated with the homemade pacifier.

A. Ask about pain. B. Provide mouth care. C. Offer fluids. D. Administer oxygen.

Correct Answer is D

Explanation

A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.

B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.

C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.

D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a clinic visit, the practical nurse (PN) observes an infant sucking on a pacifier that is made from a bottle nipple and stuffed with cotton. What should the PM do?

Correct Answer is A

Explanation

The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?

Correct Answer is D

Explanation

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