A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Determine the client's usual bowel pattern.

Choice A rationale:

Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.

Choice B rationale:

Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.

Choice C rationale:

Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.

Choice D rationale:

Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.

The correct answer is Choice A:

Collect fingerstick glucose levels.

Choice A rationale:

When a client is receiving total parenteral nutrition (TPN), it means they are receiving nutrients directly into the bloodstream, bypassing the digestive system. TPN often contains high levels of glucose, which can lead to hyperglycemia. Regular monitoring of blood glucose levels are crucial to detect and manage hyperglycemia effectively, especially in clients at risk for diabetes or those with impaired glucose metabolism.

Choice B rationale:

Implementing bleeding precautions (Choice B) is important for clients on anticoagulant therapy or with bleeding disorders. However, it is not the most important intervention for a client receiving TPN. Monitoring glucose levels takes precedence in this case.

Choice C rationale:

Obtaining daily weights is an important intervention to assess fluid balance and nutritional status in clients receiving TPN. However, it is not the most critical intervention compared to monitoring glucose levels to prevent complications of hyperglycemia.

Choice D rationale:

Checking urine for albumin is important in assessing kidney function and detecting proteinuria. While it is a valid nursing intervention, it is not the most important consideration for a client on TPN. Monitoring glucose levels is of higher priority.