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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
Correct Answer is C
Explanation
The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.
Choice A rationale:
Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.
Choice B rationale:
Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.
Choice C rationale:
Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.
Choice D rationale:
Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.
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