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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Accommodation refers to the ability of the eyes to adjust and focus on objects at diﬀerent distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.

To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.

Let's brieﬂy evaluate the other options:

a) Consensual pupillary constriction present.

Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.

Therefore, it is not the appropriate documentation for the given scenario.

b) Nystagmus present with pupillary focus.

Nystagmus refers to involuntary eye movements that can aﬀect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.

d) Peripheral vision intact.

Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.

In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.

A. Hypertension B. Tinnitus C. Hypotension D. Tachycardia

Correct Answer is A

Explanation

Choice A reason: Hypertension is a manifestation of increased intracranial pressure because it is part of the Cushing's triad, which is a set of signs that indicate increased intracranial pressure and impaired cerebral perfusion. The other signs of Cushing's triad are bradycardia and irregular respirations.

Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure because it is a symptom of hearing loss, ear infection, or ear damage, not increased intracranial pressurE. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors such as exposure to loud noise, aging, or medication side effects.

Choice C reason: Hypotension is not a manifestation of increased intracranial pressure because it is a sign of decreased blood pressure, not increased intracranial pressurE. Hypotension can be caused by various factors such as dehydration, blood loss, or shock.

Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure because it is a sign of increased heart rate, not increased intracranial pressurE. Tachycardia can be caused by various factors such as anxiety, fever, or pain.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

Correct Answer is C

Explanation

A nurse is monitoring a client who had a cerebral aneurysm rupturE. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Correct Answer is A

Explanation

A nurse educator is teaching a group of nursing students how to become effective leaders. The nursing students should recognize that an effective nurse leader has which of the following qualities? SELECT ALL THAT APPLY

A client diagnosed with bipolar disorder has recently started taking lamotrigine as part of their medication regimen. Which of the following would be an essential teaching point to include regarding the medication?

The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY

A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide?

The nurse is providing education on epidemiology to a nursing student. Which of the following statements indicates the importance of epidemiology to the community health nurse? SELECT ALL THAT APPLY

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

The nurse is developing an activity plan for a client. The nurse should recognize that which activity plan would best conserve the client's energy without compromising physical or mental health?