During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?
A Write an incident report about the bruises on the infant.
B Review the labor and delivery record for birth trauma.
C Record the size and location of the areas in the infant's chart.
D Notify the pediatrician of a possible bleeding problem with the infant.
The Correct Answer is C
A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Checks the medical record for the correct signed consent form prior to the examination. - Verifying that the correct consent form is signed and present in the medical record before the invasive examination is crucial to ensure the procedure is performed with proper authorization.
B. Explains the examination and asks the client to sign the consent form. - While it's important to explain the examination, obtaining consent typically involves the healthcare provider or a designated professional.
C. Explains to a family member and obtains their signature on the consent form. - Consent generally needs to be obtained directly from the client or their legally authorized representative, not just a family member.
D. Asks if the client understands the exam and why the consent form must be signed. - While educating the client about the procedure and the purpose of consent is important, it doesn't cover the formal process of obtaining and verifying the consent form.
Correct Answer is C
Explanation
A. Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B. Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.
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