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
Explanation
Choice A reason: Collaborating with physical therapist to develop programs for injured employees to return to work is not a secondary prevention strategy, but rather a tertiary prevention strategy, which involves restoring and rehabilitating the health and function of individuals who have experienced illness or injury.
Choice B reason: Helping plant workers identify signs of carpal tunnel syndrome is a secondary prevention strategy, which involves detecting and treating health problems early before they become more serious or complicateD.
Choice C reason: Organizing an influenza immunization campaign is not a secondary prevention strategy, but rather a primary prevention strategy, which involves preventing or reducing the occurrence or severity of health problems before they happen.
Choice D reason: Teaching plant workers about proper lifting techniques is not a secondary prevention strategy, but rather a primary prevention strategy, which involves preventing or reducing the occurrence or severity of health problems before they happen.
Correct Answer is C
Explanation
Choice A reason: Delivering a clean voided urine specimen to the laboratory is not the first task that the AP should complete because it is not urgent or time-sensitivE. The specimen can be stored in a refrigerator or on ice until it is delivereD.
Choice B reason: Feeding a client who has bilateral casts due to upper arm fractures is not the first task that the AP should complete because it is not critical or life-threateninG. The client can wait until after breakfast to receive assistance with feedinG.
Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast is the first task that the AP should complete because it is essential and priority. The client needs to have their blood glucose level checked before receiving insulin to prevent hypoglycemia or hyperglycemiA.
Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is not the first task that the AP should complete because it is not important or necessary. The client can use other alternatives such as paper towels or napkins until they get more tissues.
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