The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?
The six-hour-old with a large sacral "stork bite".
The two-day-old with negative Ortolani's sign.
The ten-hour-old with circumoral cyanosis.
The one-day-old with a positive Babinski's reflex.
The Correct Answer is C
Circumoral cyanosis, which is bluish discoloration around the mouth, can be a sign of inadequate oxygenation. It suggests that there may be an issue with the infant's respiratory or cardiovascular system, potentially indicating respiratory distress or a cardiac problem. Prompt assessment and intervention are necessary to determine the cause of the cyanosis and ensure the infant's well-being.
A. The six-hour-old infant with a large sacral "stork bite" refers to a common birthmark caused by dilated blood vessels. While it may be important to assess the birthmark and document its presence, it is not an urgent concern requiring immediate attention.
B. The two-day-old infant with a negative Ortolani's sign refers to a specific maneuver used to assess for developmental hip dysplasia or dislocation. A negative Ortolani sign indicates that there is no evidence of hip dislocation. While it is important to assess the infant's hips and document the findings, it does not require immediate attention.
D. The one-day-old infant with a positive Babinski's reflex refers to an abnormal response in which the infant's toes fan out and the big toe dorsiflexes when the sole of the foot is stimulated. While a positive Babinski's reflex can be a normal finding in infants under a certain age, it is important to assess the infant's neurological status. However, it does not require immediate attention compared to the infant with circumoral cyanosis, which indicates potential respiratory or cardiovascular distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.
Correct Answer is ["0.75ml"]
Explanation
To calculate the volume of medication to administer, we can use the following conversion: 1 mg = 1000 mcg
Given that the prescribed dose is 150 mcg/day, we need to convert it to milligrams: 150 mcg = 150/1000 mg = 0.15 mg
Since the medication is available in 0.2 mg/mL vials, we can calculate the volume to administer using the following equation:
Volume (mL) = Dose (mg) / Concentration (mg/mL) Volume (mL) = 0.15 mg / 0.2 mg/mL
Volume (mL) = 0.75 mL
Therefore, the practical nurse (PN) should administer 0.75 mL of the medication.
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