The practical nurse (PN) is caring for a 3-month-old infant with a head injury who had a seizure episode. The infant has a high-pitched cry and is irritable. The caregiver reports that the infant rolled over and fell onto the carpeted floor. Which action should the PN take?
Obtain a heel stick glucose.
Report injury details to the charge nurse.
Initiate strict intake and output measurements.
Swaddle the infant in a blanket.
The Correct Answer is B
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The best response for the PN to provide is that **an immunization may be administered for hepatitis B, and a consent form must be signed**. Phytonadione is a form of vitamin K that is given to newborns to prevent vitamin K deficiency bleeding (VKDB)¹. Vitamin K should be administered to all newborn infants weighing>1500 g as a single, intramuscular dose of 1 mg within 6 hours of birth¹. However, this is not the only injection your baby may receive while in the newborn nursery. An immunization for hepatitis B may also be administered before you can go home⁴.
Correct Answer is B
Explanation
The information that poses the greatest risk for developing postpartum endometritis in this situation is that the client experienced spontaneous rupture of membranes (SROM) for 36 hours prior to delivery. SROM for an extended period of time increases the risk of infection, including postpartum endometritis, which is an infection of the uterus. The practical nurse (PN) should recognize this risk factor and monitor the client closely for signs of infection. The other information listed may also be important to consider, but SROM for 36 hours poses the greatest risk for developing postpartum endometritis in this situation.
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