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:
- 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.
- 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.
- 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 C
Explanation
The correct answer is choice C - IV infusion site is infiltrated. Choice A rationale:
The client reports feeling nauseous. While this symptom should be monitored, it is not the most crucial finding to report for a client in Addison's crisis. Nausea can be a common symptom during various medical conditions and may not warrant immediate action.
Choice B rationale:
Has not voided in four hours. While monitoring urine output is important, it may not be the most critical finding in Addison's crisis. Other symptoms like electrolyte imbalances and
circulatory collapse is more concerning in this scenario.
Choice C rationale:
IV infusion site is infiltrated. In Addison's crisis, the client's condition may be precarious, and any complications with IV therapy could worsen the situation. It is essential to report this finding promptly to prevent further complications.
Choice D rationale:
A serum glucose level of 85 mg/dL. While monitoring glucose levels is essential in many situations, a glucose level of 85 mg/dL is within the reference range, which means it is not the most critical finding in Addison's crisis.
Correct Answer is C
Explanation
The correct answer is choice c. Tell the UAP to continue because the unconscious client is positioned safely.
Choice A rationale:
Enrolling the UAP in a hospital education class on conducting safe client care is a proactive measure, but it is not an immediate action required in this scenario. The UAP is already performing the task correctly.
Choice B rationale:
Praising the UAP for doing the oral hygiene and encouraging family participation is positive reinforcement, but it does not address the immediate task at hand. The focus should be on ensuring the client’s safety during the procedure.
Choice C rationale:
Telling the UAP to continue because the unconscious client is positioned safely is the correct action. The side-lying position with an emesis basin under the chin is appropriate for an unconscious client as it helps prevent aspiration by allowing secretions to drain out of the mouth.
Choice D rationale:
Stopping the procedure and telling the UAP to place the client in a Fowler’s position is incorrect. The Fowler’s position is not suitable for oral hygiene in an unconscious client as it increases the risk of aspiration.
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