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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
Correct Answer is A
Explanation
Choice A rationale: Safety is the priority when a client experiences auditory hallucinations. The nurse must determine if the voices are "command hallucinations" that might instruct the client to harm themselves or others.
Choice B rationale: While substance use can cause psychosis, this is a secondary assessment. Identifying immediate risk for violence or self-harm takes precedence over determining the specific chemical etiology of the behavior.
Choice C rationale: Establishing the onset of symptoms helps with chronic versus acute diagnosis, but it does not address the immediate safety risk posed by potentially dangerous instructions from the voices.
Choice D rationale: Assessing the client's insight into their condition is important for long-term treatment planning, but it is less critical than identifying the content and intent of the hallucinations.
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