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 A
Explanation
Choice A reason: Administering corticosteroids is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that reduces inflammation and relieves acute exacerbations of multiple sclerosis, but does not affect the client's physical function or mobility.
Choice B reason: Turning and repositioning every 2 hours is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a nursing intervention that prevents pressure ulcers and promotes skin integrity, but does not enhance the client's circulation or muscle activity.
Choice C reason: Administering interferon is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that modifies the immune system and delays the progression of multiple sclerosis, but does not improve the client's physical function or mobility.
Choice D reason: Encouraging range-of-motion exercises is an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a physical activity that improves the client's blood flow, flexibility, and muscle tone, as well as prevents contractures and spasticity.
Correct Answer is D
Explanation
Choice A reason: Natural history of disease is not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a description of how a disease progresses over time from exposure to outcome in the absence of intervention.
Choice B reason: Health promotion is not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a process of enabling people to increase control over and improve their health through education, empowerment, and policy changE.
Choice C reason: Levels of prevention are not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a classification of interventions based on their timing and purpose in relation to disease occurrencE.
Choice D reason: Epidemiologic triangle is an approach that explains the factors that allow the reproduction and spread of infectious disease, by identifying and analyzing three elements: agent (the cause of disease), host (the person who gets sick), and environment (the conditions that affect transmission).
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