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 B
Explanation
Elevations in troponin I and CK-MB levels indicate myocardial damage, which can result from insufficient blood supply to the heart muscle due to coronary artery disease. When the heart muscle is damaged, it can lead to abnormal electrical activity and rhythm disturbances, known as cardiac dysrhythmias. These dysrhythmias can be life-threatening and require immediate attention.
Transient ischemic attack (TIA) refers to a temporary interruption of blood flow to the brain, which is not directly related to the elevated troponin I and CK-MB levels. Therefore, monitoring neurological vital signs for TIA is not the most significant risk in this case.
Pulmonary embolism, while it is a serious condition, is not directly indicated by the elevated troponin I and CK-MB levels. Lifestyle modifications may be important for managing coronary artery disease but are not the most significant risk based on the given information.
Recurrent long-term angina pain and subsequent myocardial infarction (MI) may be a concern for the client with coronary artery disease, but the elevated troponin I and CK-MB levels suggest that myocardial damage has already occurred. The focus at this point would be on managing the acute myocardial damage and the risk of cardiac dysrhythmias.
Correct Answer is D
Explanation
Choice A reason:
Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.
Choice B reason:
Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.
Choice C reason:
Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.
Choice D reason:
Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.
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