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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.
Correct Answer is B
Explanation
The priority goal for the practical nurse (PN) in the antepartum clinic is to ensure that the client recognizes the dangers of alcohol use during pregnancy. Alcohol consumption during pregnancy can lead to fetal alcohol syndrome and other developmental disorders. It is important for the client to understand the risks associated with alcohol use and to avoid it during pregnancy. The other goals are also important but recognizing the dangers of alcohol use takes priority.
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