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 A
Explanation
In this scenario, the dentist is increasing the amount of dairy products in her diet with the aim of reducing the risk of gingivitis due to her family history of cancer. However, the practical nurse (PN) should respond by suggesting that an increase in fruits and vegetables would be more beneficial.
Fruits and vegetables are rich in essential vitamins, minerals, and antioxidants, which can help support overall oral health and reduce the risk of gingivitis. They provide a wide range of nutrients that are important for maintaining healthy gums and teeth.
While dairy products can contribute to overall dental health due to their calcium content, they should not be solely relied upon as the primary means of preventing gingivitis or reducing the risk of cancer. A well- rounded and balanced diet, including plenty of fruits and vegetables, is essential for optimal oral health.
Options b, c, and d are not directly related to the dentist's concern about gingivitis and the increased consumption of dairy products. Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis. Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency. Providing written information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.
Correct Answer is B
Explanation
After a hip arthroplasty with prosthesis placement, it is important to follow specific precautions to protect the surgical site and prevent dislocation of the hip joint. One common precaution is to avoid excessive internal rotation, adduction, and f
The other observations mentioned in the scenario are correct and demonstrate appropriate knowledge of the turning procedure:
A. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents adduction of the legs, which can cause hip dislocation.
C. Keeping the back straight and knees bent when moving the client promotes proper body mechanics and reduces the risk of injury to the UAPs.
D. Using a turning sheet under the client for turning and repositioning helps reduce friction and shearing forces, making the process safer and more comfortable for the client.
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