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

Turn the infant onto the right side.

Give oxygen by positive pressure

Suction the oral and nasal passages.

Stimulate the infant to cry.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.

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Correct Answer is B

Explanation

Tell the client that the PN will verify that the dispensed medication is the valid prescription. Choice A rationale:

Explaining that the healthcare provider probably prescribed a different medication while the client is hospitalized (Choice A) may create confusion or concern for the client. It is essential to reassure the client and take appropriate action to address the discrepancy in the appearance of the medication.

Choice C rationale:

Explaining that the pharmacy often substitutes generic equivalents for more expensive brands (Choice C) is not applicable in this situation since the client is expressing concern about the appearance of the medication prescribed by the healthcare provider, not a substitution by the pharmacy.

Choice D rationale:

Telling the client that he is probably confused since being hospitalized tends to disorient clients (Choice D) is dismissive of the client's concerns. It is crucial to acknowledge the client's observation and address the issue professionally.

A. Heating pad B. Body lotion C. Soft blanket D. Moist clothes

Correct Answer is C

Explanation

The correct answer is Choice C. Soft blanket.

Choice A rationale:

A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.

Choice B rationale:

The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.

Choice C rationale:

The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.

Choice D rationale:

Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond?

Correct Answer is B

Explanation

A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?

Correct Answer is C

Explanation

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