A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing.

Which action should the nurse take first?

Ask the mother if any visitors were expected to arrive.

Match ID bands of all infants and mothers on the unit.

Determine if the newborn is in the nursery.

Activate the lockdown procedure.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Activate the lockdown procedure.

Choice A rationale:

Asking the mother if any visitors were expected to arrive is important for gathering information, but it is not the immediate priority when a newborn is missing. The primary concern is to ensure the safety and security of the infant.

Choice B rationale:

Matching ID bands of all infants and mothers on the unit is a crucial step in verifying the identity of the newborn, but it should be done after ensuring that the unit is secure and the baby cannot be taken out of the facility.

Choice C rationale:

Determining if the newborn is in the nursery is also important, but it should be done after securing the unit to prevent any potential abduction.

Choice D rationale:

Activating the lockdown procedure is the first and most critical action. This ensures that all exits are secured, preventing anyone from leaving the unit with the infant. It is a safety measure to protect the newborn and is the immediate priority in such situations.

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Correct Answer is A

Explanation

Choice A rationale:

"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.

Choice B rationale:

"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.

Choice C rationale:

"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.

Choice D rationale:

"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.

A. Palpate for pedal edema. B. Assess blood pressure. C. Measure body temperature. D. Observe breathing patterns.

Correct Answer is D,B,C,A

Explanation

Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.

2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.

3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.

4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.

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A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment?

Correct Answer is A

Explanation

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

Correct Answer is D,B,C,A

Explanation

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A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing.

Which action should the nurse take first?