The practical nurse (PN) is caring for a 3-month-old infant with a head injury who had a seizure episode. The infant has a high-pitched cry and is irritable. The caregiver reports that the infant rolled over and fell onto the carpeted floor. Which action should the PN take?
Obtain a heel stick glucose.
Report injury details to the charge nurse.
Initiate strict intake and output measurements.
Swaddle the infant in a blanket.
The Correct Answer is B
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The action by the PN that is likely to facilitate accurate responses to personal and social history questions is to **request that the mother leave the exam room**. The personal and social history contains many areas of special sensitivity to adolescents including such issues as drug and alcohol use and sexual activity. The teen should provide the personal and social history, not the parent⁴.
Correct Answer is C
Explanation
Phyto menadione injectable, also known as vitamin K1, is commonly given to newborns to prevent hemorrhagic disease of the newborn (HDN), a bleeding disorder that can occur due to vitamin K deficiency in the first few days of life. Vitamin K is important for the production of clotting factors in the liver, and newborns are at risk of vitamin K deficiency because it does not cross the placenta well and their intestinal flora is not yet established. The other options do not accurately describe the purpose of administering Phyto menadione injectable to newborns.
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