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 B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
Correct Answer is A
Explanation
A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.
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