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: "Move objects away from the client." This instruction should be included in the teaching because it can prevent injury and protect the client from harm during a seizurE.

Choice B reason: "Restrain the client." This instruction should not be included in the teaching because it can cause injury and increase agitation and anxiety for the client during a seizurE.

Choice C reason: "Place the client on his back." This instruction should not be included in the teaching because it can increase the risk of aspiration and airway obstruction for the client during a seizurE.

Choice D reason: "Insert a padded tongue blade into the client's moutH." This instruction should not be included in the teaching because it can cause injury and choking for the client during a seizurE.

A. Inability to take risks. B. Never considers being a follower. C. Ability to set priorities. D. Integrity E. Critical care certification.

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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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

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