The practical nurse (PN) is preparing for shift change.

Which task has the highest priority and should be completed first?

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.

The correct answer is choice A: Never scratch under the cast.

Choice A rationale:

It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.

Choice B rationale:

While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.

Choice C rationale:

Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.

Choice D rationale:

Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.