The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?
Obtain blood glucose level.
Burp the infant every two-hours.
Wrap him with a warm blanket.
Give prescribed analgesic.
The Correct Answer is D
Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.
Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.
Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.
Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Performing a physical assessment of the newborn is important but should not be the first action when the infant is handed to the nurse during a cesarean delivery.
Choice B: Determining an APGAR score is important for assessing the newborn's overall condition, but allowing the mother to touch the infant should be the first action.
Choice C: Drying the infant under a warming unit is an important step to maintain the infant's body temperature, but allowing the mother to touch the infant should be prioritized first.
Choice D: Allowing the mother to touch the infant immediately after delivery is a crucial bonding and comforting moment for both the mother and the newborn. It should be the first action taken before other assessments or interventions.
Correct Answer is C
Explanation
A. A minimally furnished room may be beneficial for safety, but it is not the primary consideration for room assignment.
B. A room with multiple roommates may increase stimulation, which can worsen manic symptoms.
C. A quiet room away from the nurse's station helps reduce environmental stimuli, which can help manage the client's elated state.
D. A bright-colored room near the recreation area may increase sensory stimulation, potentially worsening manic symptoms.
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