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 ["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.
Correct Answer is ["C","D"]
Explanation
Choice A reason: Inability to take risks is not a quality of an effective nurse leader because it can limit the nurse's creativity, innovation, and problem-solving skills, as well as prevent the nurse from exploring new opportunities and learning from mistakes.
Choice B reason: Never considers being a follower is not a quality of an effective nurse leader because it can isolate the nurse from the team, hinder collaboration and communication, and create a sense of superiority and arrogancE.
Choice C reason: Ability to set priorities is a quality of an effective nurse leader because it can help the nurse manage time, resources, and tasks efficiently and effectively, as well as focus on the most important and urgent goals and outcomes.
Choice D reason: Integrity is a quality of an effective nurse leader because it can foster trust, respect, and honesty among the team, as well as demonstrate the nurse's adherence to ethical principles and professional standards.
Choice E reason: Critical care certification is not a quality of an effective nurse leader because it is a credential that reflects the nurse's knowledge and competence in a specific area of practice, but not necessarily their leadership skills or abilities.
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