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
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Correct Answer is B
Explanation
Choice A reason: Mitral valve disease is not a disorder that makes clients especially vulnerable to ozone effects because it is a condition that affects the heart valve that regulates blood flow between the left atrium and left ventricle, not the lungs or airways.
Choice B reason: Asthma is a disorder that makes clients especially vulnerable to ozone effects because it is a condition that causes inflammation, narrowing, and mucus production in the airways, which can worsen when exposed to ozone, a gas that irritates and damages lung tissuE.
Choice C reason: Nasal polyps are not a disorder that makes clients especially vulnerable to ozone effects because they are benign growths that occur in the lining of the nose or sinuses, not the lungs or airways.
Choice D reason: Seasonal allergies are not a disorder that makes clients especially vulnerable to ozone effects because they are immune system reactions to certain substances such as pollen or mold, not ozone, which is a chemical pollutant.
Correct Answer is B
Explanation
Choice A reason: A black tag is not an appropriate priority tag for this client because it indicates that the client is dead or has injuries that are incompatible with life and survival is unlikely even with treatment.
Choice B reason: A red tag is an appropriate priority tag for this client because it indicates that the client has life-threatening injuries that require immediate attention and treatment to survivE.
Choice C reason: A green tag is not an appropriate priority tag for this client because it indicates that the client has minor injuries that do not require immediate attention and treatment and can wait until the more urgent cases are handleD.
Choice D reason: A yellow tag is not an appropriate priority tag for this client because it indicates that the client has serious injuries that require attention and treatment within a short time, but can wait until the more critical cases are handleD.
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