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 A
Explanation
The correct answer is Choice A:
Collect fingerstick glucose levels.
Choice A rationale:
When a client is receiving total parenteral nutrition (TPN), it means they are receiving nutrients directly into the bloodstream, bypassing the digestive system. TPN often contains high levels of glucose, which can lead to hyperglycemia. Regular monitoring of blood glucose levels are crucial to detect and manage hyperglycemia effectively, especially in clients at risk for diabetes or those with impaired glucose metabolism.
Choice B rationale:
Implementing bleeding precautions (Choice B) is important for clients on anticoagulant therapy or with bleeding disorders. However, it is not the most important intervention for a client receiving TPN. Monitoring glucose levels takes precedence in this case.
Choice C rationale:
Obtaining daily weights is an important intervention to assess fluid balance and nutritional status in clients receiving TPN. However, it is not the most critical intervention compared to monitoring glucose levels to prevent complications of hyperglycemia.
Choice D rationale:
Checking urine for albumin is important in assessing kidney function and detecting proteinuria. While it is a valid nursing intervention, it is not the most important consideration for a client on TPN. Monitoring glucose levels is of higher priority.
Correct Answer is B
Explanation
The correct answer is choice B: Monitor the client's hearing. Choice A rationale:
Observing the skin for a rash is not relevant to assessing for signs of ototoxicity. Aminoglycosides can cause skin reactions, but this is not a specific sign of ototoxicity.
Choice B rationale:
Monitoring the client's hearing is essential when administering aminoglycosides because these medications can cause ototoxicity, which is damage to the inner ear and auditory nerve leading to hearing loss or tinnitus. Regular hearing assessments can help detect any changes in hearing and prompt appropriate interventions.
Choice C rationale:
Measuring the urinary output is not directly related to assessing for ototoxicity.
Aminoglycosides can cause kidney toxicity, but this is a separate concern from ototoxicity. Choice D rationale:
Checking for changes in vision is not specifically associated with aminoglycoside administration. Vision changes are not a common side effect of these medications, so it would not be a primary assessment in this situation.
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