The nurse is caring for a 3-hour-old newborn infant and is completing an assessment.
The nurse observes cyanosis on the infant's hands and feet.
What is the priority nursing intervention?
Check infant's temperature for hypothermia.
Activate a code blue or emergency response.
Administer blow-by oxygen to the infant.
Continue to monitor because this is normal.
The Correct Answer is D
Newborn transitions involve significant vasomotor changes during the first few hours of life. Understanding the physiological basis of acrocyanosis versus central cyanosis is critical to determine whether clinical findings represent a normal adaptation or a sign of respiratory or cardiac distress.
Choice A rationale
Hypothermia can cause peripheral vasoconstriction, but acrocyanosis is a standard finding in newborns regardless of temperature. While maintaining thermoregulation is important, the priority is recognizing the observation as a normal physiological transition during the first hours.
Choice B rationale
Activating an emergency response is indicated for central cyanosis, which involves the tongue and mucous membranes, signaling systemic hypoxia. Acrocyanosis limited to extremities does not indicate a life-threatening emergency requiring a code blue or resuscitation.
Choice C rationale
Blow-by oxygen is used for infants showing signs of respiratory distress or central cyanosis. Administering oxygen for isolated peripheral cyanosis is unnecessary and potentially harmful, as it does not address the normal vasomotor instability present in newborns.
Choice D rationale
Acrocyanosis, characterized by bluish hands and feet, is a normal finding during the first 24 to 48 hours of life. It results from poor peripheral circulation and vasomotor instability. Continued monitoring is the most appropriate nursing action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse must identify signs of estrogen-related thromboembolism. Estrogen increases clotting factor synthesis, raising the risk for pulmonary embolism. Recognizing cardiovascular distress and prioritizing urgent medical intervention is essential when assessing clients on hormonal therapy experiencing dyspnea or chest pain.
Choice A rationale
Shortness of breath and chest pain are never considered expected side effects of oral contraceptives. These symptoms indicate pulmonary embolism or myocardial infarction, requiring immediate medical evaluation rather than simple monitoring of common hormonal reactions.
Choice B rationale
Oral contraceptives increase the risk of deep vein thrombosis and pulmonary embolism. Sudden chest pain and dyspnea suggest a life-threatening clot. The client needs emergency care to stabilize respiratory function and initiate anticoagulation therapy immediately.
Choice C rationale
Waiting until the next day is dangerous because pulmonary embolism can cause rapid respiratory failure or death. While stopping the medication is necessary, the acute physical symptoms require higher acuity care than an outpatient clinic appointment.
Choice D rationale
Advising the client to continue the medication is incorrect and potentially fatal. Estrogen-containing pills exacerbate hypercoagulability. Ignoring signs of chest pain and dyspnea delays life-saving treatment for a likely pulmonary or cardiac vascular obstruction.
Correct Answer is B
Explanation
This obstetric scenario requires the application of maternal-fetal nursing knowledge regarding labor complications. Assessment priorities in the active phase must distinguish between normal labor progression and life-threatening emergencies like placental abruption or uterine rupture, requiring physical evaluation before intervention.
Choice A rationale
Pain medications might mask symptoms of a serious complication like placental abruption. Providing pharmacological relief without first assessing the source of sudden, severe abdominal pain violates the nursing process and delays necessary emergency interventions.
Choice B rationale
Assessing for vaginal bleeding and uterine tone is the priority to evaluate for placental abruption. Severe, constant abdominal pain during labor is an emergency signal. The normal assessment findings would show intermittent contraction-related discomfort.
Choice C rationale
Pulse oximetry measures systemic oxygen saturation but is not the most specific assessment for a fetal or uterine emergency. While vital signs are important, they do not pinpoint the cause of the acute abdominal pain.
Choice D rationale
Preparing for surgery is a premature action before a definitive assessment of the pain is performed. Although a cesarean may eventually be necessary, the nurse must first gather clinical evidence to justify such an intervention.
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