The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?
Obtain blood glucose level.
Burp the infant every two-hours.
Wrap him with a warm blanket.
Give prescribed analgesic.
The Correct Answer is D
Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.
Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.
Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.
Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
To determine the volume of amoxicillin-clavulanic acid suspension to administer in a single dose, you can use the following calculation:
Dose prescribed: 300 mg Concentration available: 250 mg/5 mL
First, calculate the dose per mL:
Dose per mL = Concentration available (mg/mL) Dose per mL = 250 mg/5 mL
Dose per mL = 50 mg/mL
Now, calculate the mL needed for the prescribed dose:
Volume (mL) = Dose prescribed (mg) / Dose per mL Volume (mL) = 300 mg / 50 mg/mL
Volume (mL) = 6 mL
Therefore, the nurse should administer 6 mL of amoxicillin-clavulanic acid suspension in a single dose.
Correct Answer is ["B","C","D"]
Explanation
Choice A: Closing the blinds to darken the room may not be the immediate priority during a seizure. Ensuring the safety and well-being of the child takes precedence.
Choice B: Asking the mother to release the child is an important action. It is essential to prevent any further physical restraint during a seizure, as it can cause harm to the child or the person attempting to restrain them.
Choice C: Monitoring the child's airway and tongue is crucial during a seizure to prevent any obstruction that could interfere with breathing. It is important to ensure the child does not choke on saliva or vomit.
Choice D: Administering an anticonvulsant medication may be necessary in certain situations, especially if the seizure persists or is prolonged. The healthcare provider's orders should be followed for the administration of appropriate medications
Choice E: Placing pillows inside the side rails is not a relevant intervention during a seizure. The focus should be on ensuring the child's safety, assessing their airway, and providing appropriate care during the seizure.
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