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 B
Explanation
Choice A rationale:
While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.
Choice C rationale:
Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.
Choice D rationale:
Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.
Correct Answer is B
Explanation
Choice A rationale:
Crushing the medication and administering it in applesauce might alter its pharmacokinetics, rendering it ineffective or causing it to act too quickly. Sublingual tablets are designed to dissolve under the tongue for rapid absorption into the bloodstream. Crushing the tablet and mixing it with applesauce could change its intended mode of action.
Choice B rationale:
Placing the tablet under the client's tongue is the correct action for a sublingual tablet. Sublingual administration allows the medication to dissolve directly into the bloodstream through the sublingual mucosa, bypassing the digestive system and providing rapid onset of action.
Choice C rationale:
Obtaining a liquid form of the medication might be an option, but it may not always be available. Additionally, some medications are not available in liquid forms, and the liquid form might have a slower onset of action compared to the sublingual route.
Choice D rationale:
Placing the tablet inside the client's cheek is known as the buccal route of administration. While this route is also for oral absorption, sublingual administration is preferred for specific medications designed for rapid absorption.
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