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.

Suction the oral and nasal passages.

Give oxygen by positive pressure.

Stimulate the infant to cry.

Answer and Explanation

The Correct Answer is B

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Nurses performing duties outside of the nurses' typical job description is not a component of a disaster plan. Nurses should only perform tasks that are within their scope of practice, license, and competencE.

Choice B reason: A plan for comprehensive practice drills is a component of a disaster plan. Nurses should be involved in conducting regular drills to test and improve the preparedness and response of the staff and facility.

Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component of a disaster plan. Nurses should be involved in assessing and securing the necessary resources to provide adequate care and support for the clients and staff during a disaster.

Choice D reason: An internal and external communication plan is a component of a disaster plan. Nurses should be involved in establishing and maintaining effective communication channels with other health care providers, agencies, authorities, media, and community during a disaster.

Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component of a disaster plan. Nurses should not discharge clients without proper assessment, documentation, education, and follow-up arrangements.

A. Encourage community members to practice fire drills B. Identify community members who have disabilities C. Provide first aid to community members affected by a tornado D. Assist community members in developing a disaster plan

Correct Answer is B

Explanation

Choice A reason: Encouraging community members to practice fire drills is an activity that is a part of the prevention/mitigation phase of the disaster management cycle because it can reduce the risk of injury or death from fire by increasing the awareness and preparedness of the community.

Choice B reason: Identifying community members who have disabilities is an activity that is a part of the prevention/mitigation phase of the disaster management cycle because it can reduce the vulnerability of these individuals by ensuring that they have access to appropriate resources and assistance in case of a disaster.

Choice C reason: Providing first aid to community members affected by a tornado is not an activity that is a part of the prevention/mitigation phase of the disaster management cycle, but rather the response phase, which involves delivering immediate and short-term assistance to save lives and meet basic needs during and after a disaster.

Choice D reason: Assisting community members in developing a disaster plan is not an activity that is a part of the prevention/mitigation phase of the disaster management cycle, but rather the preparedness phase, which involves enhancing the readiness and capabilities of individuals, organizations, and communities to respond to and recover from a disaster.

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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

The hospital's Emergency Operations Committee is working on their disaster plan. In which components should nurses be included? SELECT ALL THAT APPLY.

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Correct Answer is B

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