Answer to Question 1
A, B, C, E
Feedback:
Four goals for immediate management of the newborn are to (1) establish and maintain an airway and respirations, (2) provide warmth and prevent hypothermia, (3) provide a safe environment and routine preventive measures, and (4) promote maternalinfant attachment. In some facilities, newborns receive a complete body bath and shampoo after they are stable and their body temperature is within normal limits, but this is not an immediate goal. Mongolian spots are a normal skin alteration and should be documented, but not reported.
Answer to Question 2
A
Feedback:
The nurse should document the skin lesion as purpura. Purpura is a skin lesion characterized by discoloration of skin owing to blood in the tissue. A laceration is a skin lesion that appears as a jagged cut through the skin or tissue. Excoriation is a skin lesion that appears as an abrasion or scraped area of the epidermis. Dermatitis is a skin lesion characterized by skin inflammation.
The patient and his family meet with the nurse to discuss progress on the patient care plan.
The nurse needs to note the source of the patient health history
A, A nurse is adding a medication to an IV line as a piggyback
Performing a Gram Stain
Personal care setting.
ACCM Definitions of ICU Levels of Care