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 B

Explanation

Choice A rationale:

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice C rationale:

Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.

Choice D rationale:

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

A. Continue with the blood pressure assessment. B. Reposition the stethoscope over the brachial artery. C. Reinflate the cuff to a higher number. D. Note the presence of an auscultatory gap.

Correct Answer is D

Explanation

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

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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

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is D

Explanation

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

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?

A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

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?