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 A
Explanation
A. Call the healthcare provider and clarify the prescription. - If the PN suspects an error in a prescription, especially regarding a child's dosage, it's imperative to communicate concerns to the healthcare provider for clarification and potential adjustment.
B. Request verification of the prescription by the charge nurse. - While involving another nurse might provide a second opinion, it's crucial to involve the prescriber to rectify any potential prescription errors.
C. Tell the pharmacy to send an accurate child's dosage. - The prescription should be confirmed with the healthcare provider before any medication is dispensed or administered.
D. Ask another nurse if adult dosages are ever given to children. - While seeking information from peers is valuable, this situation calls for direct clarification from the prescriber to ensure proper dosing for the child.
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