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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
B. Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.
C. Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
D. Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
Correct Answer is ["B","C"]
Explanation
A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.
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