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 ["25"]
Explanation
Step 1 is: Subtract the dry diaper weight from the wet diaper weight to find the weight of the urine. 75 grams - 50 grams = 25 grams.
Step 2 is: Convert the weight of the urine from grams to milliliters, as 1 gram of urine is approximately equal to 1 mL. 25 grams = 25 mL. The urine output is 25 mL.
Correct Answer is B
Explanation
Choice A rationale
Administering ibuprofen may alleviate pain temporarily, but it does not address the underlying cause of increased pain and pressure, which could indicate a developing complication such as a perineal hematoma. Providing only symptomatic relief delays investigation and potential intervention for a serious issue.
Choice B rationale
Increased pain and pressure in the vaginal area following a perineal laceration, especially 6 hours postpartum, are classic signs of a developing perineal hematoma. This condition requires prompt medical evaluation by the healthcare provider to assess the extent of bleeding, potential for shock, and determine the need for surgical intervention.
Choice C rationale
Applying an icepack to the perineum is a common comfort measure for swelling and pain associated with lacerations. While it may provide some relief, it will not resolve a developing hematoma or significant internal bleeding that is causing increased pain and pressure. It is an insufficient intervention for the potential severity of the client's symptoms.
Choice D rationale
Providing routine perineal care, such as gentle cleansing and hygiene, is important for comfort and infection prevention. However, it does not address the acute and increasing pain and pressure that suggests a complication beyond typical postpartum discomfort. This intervention would delay necessary medical assessment for a potential hematoma.
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.