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
A resting respiratory rate of 35 breaths/minute for a 4-month-old infant is within the normal range (typically 30-60 breaths/minute). Therefore, this finding alone does not indicate acute respiratory distress.
Choice B rationale
Bilateral bronchial breath sounds are normal findings when auscultated over the trachea. However, their presence over the peripheral lung fields can indicate consolidation, such as in pneumonia. While abnormal in the periphery, it is not an isolated sign of acute respiratory distress.
Choice C rationale
Diaphragmatic respirations, also known as abdominal breathing, are the predominant and normal breathing pattern in infants and young children due to the preferential use of the diaphragm for respiration. This is not a sign of respiratory distress.
Choice D rationale
Flaring of the nares is a significant clinical sign of increased work of breathing and respiratory distress in infants. It indicates that the infant is attempting to decrease airway resistance and maximize oxygen intake by dilating the nasal passages. This is a compensatory mechanism indicating respiratory compromise.
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen and suctioning are appropriate for respiratory distress, but turning the newborn from supine to prone every 2 hours does not prevent aspiration in tracheoesophageal fistula and may increase the risk of aspiration or worsen respiratory compromise by allowing refluxed gastric contents to enter the airway.
Choice B rationale
Offering sterile water per nipple is contraindicated in suspected tracheoesophageal fistula because it poses a significant aspiration risk, as the water will likely enter the trachea. Placing the infant in a prone position does not mitigate this aspiration risk during feeding.
Choice C rationale
Inserting an orogastric tube is appropriate, but giving feedings via gavage before confirmation is dangerous due to the risk of aspiration into the lungs if a fistula is present. Confirmation via x-ray is crucial to ensure the tube is correctly placed and feeding is safe.
Choice D rationale
Keeping the infant NPO (nothing by mouth) prevents aspiration of fluids or food into the respiratory tract, which is a major complication of tracheoesophageal fistula. Elevating the head of the crib to 30 degrees uses gravity to minimize gastroesophageal reflux and further reduce the risk of aspiration.
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