While observing a mother bottle feeding a 4-month-old, the infant starts to choke.
Which action should the practical nurse (PN) take first?
Immediately suction the infant's mouth with a bulb syringe.
Monitor the infant's respirations for 15-seconds.
Have the mother turn the infant over and perform three back-blows.
Have the mother stop the feeding and sit the infant upright.
The Correct Answer is C
Choice A rationale
While suctioning with a bulb syringe may be indicated for secretions, in an active choking episode with a foreign body obstruction, it is not the immediate first action. Back-blows are more effective at dislodging the obstructing object by increasing intrathoracic pressure and creating an artificial cough.
Choice B rationale
Monitoring respirations for 15 seconds is a delay in critical intervention for an infant actively choking. An infant who is choking requires immediate, active intervention to clear the airway and restore effective breathing, as prolonged airway obstruction can quickly lead to hypoxia and cardiac arrest.
Choice C rationale
In a choking infant, the immediate and most effective first action is to perform three back-blows. This maneuver utilizes gravity and rapid increases in intrathoracic pressure to dislodge the foreign object from the airway, aiming to clear the obstruction quickly and restore ventilation.
Choice D rationale
Stopping the feeding and sitting the infant upright might be appropriate if the infant is merely gagging or coughing, but for active choking, this action alone is insufficient to dislodge an aspirated object. Active intervention like back-blows is required to overcome the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Methylergonovine is an ergot alkaloid that directly stimulates sustained uterine contractions. This action is crucial in controlling postpartum hemorrhage by compressing blood vessels within the myometrium, thereby reducing blood loss. The observed excessive bleeding with this delivery necessitates intervention to prevent complications like hypovolemic shock. Its pharmacological effect targets smooth muscle receptors in the uterus.
Choice B rationale
Routine prescription based solely on parity (number of previous pregnancies) is not standard medical practice. Methylergonovine is administered based on clinical indication, primarily to prevent or manage postpartum hemorrhage, which is determined by factors like uterine atony or excessive bleeding, not simply the number of previous births. Unnecessary administration can lead to adverse effects.
Choice C rationale
While methylergonovine does contract the uterus and prevent excess bleeding, this response is a general statement. The best response directly addresses the client's current situation and her question about why *she* is receiving it *this time*. It is crucial to explain the specific clinical reason for her individual prescription, which in this context is likely due to the increased bleeding.
Choice D rationale
This response shifts the responsibility back to the client and does not provide the requested information. It fails to address the client's direct question about the medication's purpose in her specific situation. Providing clear and concise information is essential for client education and adherence to the treatment plan.
Correct Answer is A
Explanation
Choice A rationale
Excessive swallowing after a tonsillectomy is a critical sign of postoperative hemorrhage, as blood pooling in the pharynx triggers the swallowing reflex. Promptly informing the registered nurse allows for immediate assessment, potential intervention to control bleeding, and prevention of airway compromise or hypovolemic shock.
Choice B rationale
Offering fluids to soothe the throat is contraindicated in suspected hemorrhage as it may increase the risk of aspiration or obscure the amount of blood being swallowed. It also delays the critical assessment and intervention required for active bleeding.
Choice C rationale
Administering supplemental oxygen per prescription is a supportive measure for respiratory distress. While potentially necessary if the child's oxygen saturation drops, it does not address the underlying cause of excessive swallowing, which is likely hemorrhage, and should not be prioritized over reporting the cardinal sign.
Choice D rationale
Elevating the child's head to promote drainage is a general comfort measure and may help with swelling. However, it does not directly address active bleeding. In a suspected hemorrhage, the primary concern is to identify and manage the source of bleeding, not merely to promote drainage.
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