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
Instruct the UAP to lower the bed for safety.
This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.
A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.
B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.
D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.
Correct Answer is B
Explanation
Ask the client to describe what happened.
Calling the agency-based client advocate (Choice A) should not be the first action taken in this situation. While involving an advocate might be necessary at some point, it is more appropriate to address the client's concerns and gather information about the incident first.
Completing a client adverse incident report (Choice C) is an important step to document theevent and any potential issues, but it should not be the first action taken. Before completing the report, the nurse needs to understand the situation from the client's perspective.
Informing the charge nurse of the situation (Choice D) is a reasonable step, but it should not be the first action. It may be necessary to escalate the issue, but understanding the situation from the client's viewpoint should be prioritized.
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