The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last?
Heart
Abdomen
Lungs
Throat
The Correct Answer is D
A. Heart: The heart can be assessed while the newborn is calm or asleep to obtain an accurate heart rate and rhythm. Auscultating early avoids startling the infant, allowing for a more reliable assessment.
B. Abdomen: The abdomen should be examined while the newborn is relaxed, as palpation can disturb or wake the baby. Performing this assessment early ensures accurate findings without excessive movement or crying.
C. Lungs: The lungs can be auscultated while the newborn is sleeping to hear clear, unobstructed breath sounds. A quiet, sleeping state minimizes crying, which can interfere with accurate assessment.
D. Throat: The throat examination should be performed last because it involves handling the mouth and airway, which typically awakens or irritates the newborn. This can lead to crying and distress, making it harder to assess other systems afterward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
• Right patient: Ensures the medication is given to the correct individual by verifying identifiers such as name and date of birth, reducing the risk of medication errors.
• Right medication: Confirms the nurse is administering the exact drug prescribed, preventing administration of the wrong medication due to look-alike or sound-alike names.
• Right dose: Verifies the correct amount of medication, ensuring it aligns with the provider’s order and safe dosage range to avoid toxicity or underdosing.
• Right route: Confirms the medication is given via the intended path (oral, IV, IM, etc.), as incorrect routes can alter absorption and efficacy or cause harm.
• Right time: Ensures the medication is administered at the correct interval to maintain therapeutic levels and optimize treatment effectiveness.
• Right documentation: Involves accurately recording the medication, time, dose, and route after administration to ensure legal accountability and continuity of care.
Correct Answer is C
Explanation
A. Check tube placement: Tube placement should be verified before administering any medication to ensure that the tube is in the stomach and not the respiratory tract. Checking placement afterward does not prevent complications from incorrect placement.
B. Retape the tube: Retaping may be necessary if the tube is loose, but it is not the priority action after giving medication. The immediate concern is maintaining tube patency and preventing clogging.
C. Flush the tube: Flushing the orogastric tube with sterile or tap water after medication administration is the priority. It ensures that the full dose of the drug enters the stomach, prevents drug interactions or residue buildup in the tubing, and maintains patency.
D. Remove the tube: The orogastric tube should not be removed unless specifically ordered or if there is a clinical reason. Removal immediately after medication administration would prevent ongoing nutritional or medication use and is not a standard practice.
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