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 A

Explanation

Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.

Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.

Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.

A. Give the patient extra time to perform activities. B. Teach the client to walk more quickly when ambulatinG. C. Place the client on a low-protein, low-calorie diet. D. Complete passive range-of-motion exercises daily.

Correct Answer is A

Explanation

Choice A reason: Giving the patient extra time to perform activities is an appropriate action by the nurse because it respects the patient's autonomy and dignity, and reduces frustration and anxiety. Bradykinesia is a condition of slow movement that affects people with Parkinson's disease due to decreased dopamine levels in the brain.

Choice B reason: Teaching the client to walk more quickly when ambulating is not an appropriate action by the nurse because it can increase the risk of falls and injuries, and worsen the patient's symptoms. Bradykinesia can impair the patient's balance, coordination, and gait, making it difficult to initiate and maintain movement.

Choice C reason: Placing the client on a low-protein, low-calorie diet is not an appropriate action by the nurse because it can lead to malnutrition, weight loss, and muscle wasting, which can further compromise the patient's health and function. Bradykinesia does not affect the patient's metabolism or nutritional needs.

Choice D reason: Completing passive range-of-motion exercises daily is not an appropriate action by the nurse because it does not address the underlying cause of bradykinesia, which is reduced dopamine production in the brain. Passive range-of-motion exercises are movements performed by another person without the patient's active participation, which can decrease the patient's motivation and self-efficacy.

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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?

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Correct Answer is A

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