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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Analgesics are not the most effective classification of medications for treating this pain because they are drugs that relieve pain by blocking pain signals or reducing inflammation, but they do not address the underlying cause of trigeminal neuralgia, which is compression or irritation of the trigeminal nervE.
Choice B reason: Antihistamines are not the most effective classification of medications for treating this pain because they are drugs that block histamine receptors and reduce allergic reactions, but they do not affect the function or activity of the trigeminal nervE.
Choice C reason: Antibiotics are not the most effective classification of medications for treating this pain because they are drugs that kill or inhibit bacteria and treat infections, but they do not treat trigeminal neuralgia unless it is caused by a bacterial infection, which is rarE.
Choice D reason: Anticonvulsants are the most effective classification of medications for treating this pain because they are drugs that stabilize nerve membranes and reduce nerve impulses, which can decrease the frequency and intensity of trigeminal neuralgia attacks
Correct Answer is C
Explanation
Accommodation refers to the ability of the eyes to adjust and focus on objects at different distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.
To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.
Let's briefly evaluate the other options:
a) Consensual pupillary constriction present.
Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.
Therefore, it is not the appropriate documentation for the given scenario.
b) Nystagmus present with pupillary focus.
Nystagmus refers to involuntary eye movements that can affect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.
d) Peripheral vision intact.
Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.
In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.
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