The practical nurse (PN) is assisting with the care of an infant who was born 6 hours ago and is prescribed supplemental oxygen.
Which action can the PN safely implement?
Obtain blood gas samples from the umbilical artery catheter.
Administer nebulized inhalation therapy every 4 hours.
Initiate 50% oxygen supplementation by oxygen mask.
Assess and record oxygen saturation levels every hour.
The Correct Answer is D
Choice A rationale
Obtaining blood gas samples from an umbilical artery catheter (UAC) is a procedure performed by advanced practitioners, such as physicians or specialized critical care nurses, due to the inherent risks of arterial sampling, including vasospasm, thrombosis, and infection. This is beyond the scope of practice for a practical nurse.
Choice B rationale
Administering nebulized inhalation therapy requires a specific prescription and careful assessment of the infant's respiratory status. While PN scope varies, initiating such a therapy without explicit instruction and comprehensive assessment is typically outside a PN's independent practice, especially in a neonate with evolving respiratory needs.
Choice C rationale
Initiating 50% oxygen supplementation is a significant intervention that requires a physician's order and continuous monitoring of the infant's oxygen saturation to prevent hyperoxia, which can lead to complications such as retinopathy of prematurity or pulmonary damage. A PN would not independently initiate this.
Choice D rationale
Assessing and recording oxygen saturation levels using pulse oximetry is a fundamental nursing responsibility and falls well within the scope of practice for a practical nurse. This non-invasive assessment provides crucial data regarding the infant's oxygenation status, guiding further interventions and monitoring the effectiveness of oxygen therapy. Normal range for neonates is typically 90-95% or higher.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Collecting a urine specimen for electrolytes and protein would not directly address the client's acute symptoms of restlessness and apprehension. While important for general assessment, these lab parameters are not the primary indicators of fetal distress or immediate maternal physiological deterioration in this context. Normal electrolyte ranges: sodium 135-145 mEq/L, potassium 3.5-5.0 mEq/L. Protein in urine is usually negative.
Choice B rationale
Moving the client into a dorsal recumbent position can actually exacerbate vena caval compression in a laboring client at 42-weeks gestation, potentially leading to supine hypotensive syndrome, which would worsen rather than alleviate restlessness and apprehension due to decreased cardiac output and uteroplacental perfusion.
Choice C rationale
Encouraging the client to push with the next contraction is inappropriate given her symptoms of restlessness and apprehension. These symptoms could indicate evolving complications, such as hypoxemia or even early stages of hypovolemic shock, requiring immediate assessment of vital signs and fetal well-being before encouraging active labor efforts.
Choice D rationale
Providing information about the baby's status can help alleviate the client's apprehension, especially if her symptoms are related to anxiety about the labor process or fetal well-being, which is common in intrapartum fever. Scientific rationale supports addressing psychological distress to improve coping mechanisms.
Correct Answer is A
Explanation
Choice A rationale
Meconium is an infant's first stool, composed of amniotic fluid, lanugo, bile, and intestinal epithelial cells. Most infants pass meconium within the first 24 hours of life. Failure to pass meconium within 24 hours can indicate a bowel obstruction, such as Hirschsprung's disease or meconium ileus, necessitating immediate medical evaluation.
Choice B rationale
The amount of formula consumed by a 24-hour-old infant can vary. While adequate feeding is important, not finishing a 3 oz bottle at this early stage may not be as immediately concerning as the absence of meconium, as gastric capacity is still developing.
Choice C rationale
While three wet diapers indicate adequate hydration and renal function, which is positive, the absence of meconium stool is a more critical physiological assessment requiring urgent attention due to potential underlying pathology.
Choice D rationale
The use of a bulb syringe suggests the infant may have some respiratory secretions, which can be normal variations. This finding, while noted, does not carry the same level of immediate concern as the absence of meconium passage in a 24-hour-old.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.