When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are flexed with limited abduction. Based on this finding, what action should the PN take next?
Perform range of motion to the joint.
Continue care since this is a normal finding.
Notify the healthcare provider.
Document the finding in the record.
The Correct Answer is C
Limited abduction of the legs in a newborn can be a sign of developmental dysplasia of the hip (DDH), a condition in which the hip joint is not properly formed. The practical nurse (PN) should notify the healthcare provider of this finding so that further assessment and appropriate intervention can be initiated.
Performing range of motion to the joint (A) is not appropriate without a healthcare provider's order. Continuing care as if this is a normal finding (B) is not appropriate because limited abduction of the legs in a newborn can be a sign of DDH. While documenting the finding in the record (D) is important, notifying the healthcare provider is the most important action for the PN to take next.
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Correct Answer is B
Explanation
The greatest priority for the practical nurse to monitor during the administration of epidural anesthesia is maternal blood pressure (BP). Epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return, which can result in decreased fetal perfusion and oxygenation. Therefore, it is important for the practical nurse to monitor maternal BP frequently and promptly report any significant changes to the healthcare provider. Options A, C, and D are also important assessments, but they are not the priority in this scenario.
Therefore, options A, C, and D are not answers because they are not the priority assessment during the administration of epidural anesthesia.
Correct Answer is D
Explanation
The most important behaviors for the practical nurse (PN) to monitor in this situation are argumentativeness and use of profanity. These behaviors may indicate that the client is becoming agitated and may pose a risk to themselves or others. The PN should closely monitor the client's behavior and take appropriate action to ensure the safety of the client and others on the unit. The other behaviors listed may also be important to monitor, but argumentativeness and use of profanity are the most important in this situation
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