The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery. Which infant should the PN assess first?
The ten-hour-old with circumoral cyanosis.
The one-day-old with a positive Babinski's reflex.
The two-day old with negative Ortolani's sign.
The six-hour-old with a large sacral "stork bite".
The Correct Answer is A
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
B. A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
C. A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
D. A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document this information in the medical record and report any changes or concerns.
A. Height and weight of client prior to admission are not relevant for administering pain medication and may not affect the dosage or route of the medication.
E. History of pain medication use during the past year is not relevant for administering pain medication and may not indicate the client's tolerance or preference for the medication.
Correct Answer is D
Explanation
The correct answer is choice D. Apply a pain scale to describe intensity.
Choice A rationale:
Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.
Choice B rationale:
Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.
Choice C rationale:
Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.
Choice D rationale:
Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.
By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.
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