The nurse is assessing the newborn and notes the presence of a bluish discoloration of the hands and feet. Which of the following actions would be most important for the nurse to perform next?
1. Assess the oral mucosa.
2. Obtain the newborn's temperature.
3. Apply a blanket.
4. Assess capillary refill.
1
Rationale 1: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa.
Rationale 2: The newborn may be suffering from hypothermia, but the nurse should first determine if the newborn is experiencing true cyanosis or acrocyanosis.
Rationale 3: Applying a blanket is important, but the nurse must first determine if the newborn is experiencing true cyanosis or acrocyanosis.
Rationale 4: Capillary refill is important to assess, but the most important thing to do at this point, is to determine if the newborn is experiencing true cyanosis or acrocyanosis.
You might also like to view...
Which of the following most commonly causes balanitis?
A. Tinea B. Syphilis C. Candida D. Gonorrhoea
A client with inflammatory arthritis asks about adding an anti-inflammatory herb to the medication regimen to decrease the use of prescription drugs. The nurse suggests the client discuss the efficacy of which herbs with the healthcare provider?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
A. Evening primrose B. St. John's wort C. Ginger D. Ginseng E. Bilberry
What would the nurse include when teaching an adolescent about tinea pedis?
A) "Keep your feet moist and open to the air as much as possible." B) "Dry the area between your toes really well." C) "Wear nylon or synthetic socks every day." D) "Go barefoot when you are in the locker room at school."
The patient is having a difficult time dealing with an AIDS diagnosis. The patient states, "It's not fair. I'm totally isolated from God and my family because of this. Even my father hates me for this. He won't even speak to me."
What should the nurse do? a. Tell the patient to move on and focus on getting better. b. Use therapeutic communication to establish trust and caring. c. Assure the patient that the father will accept this situation soon. d. Point out that the patient has no control and that he or she must face the consequences.