While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?

Correct Answer: B

Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.

Correct Answer: D

Rationale: In the acute stage of an unconscious patient like Mr. Franco, the most critical assessment is ensuring the patency of the airway and evaluating the adequacy of respiration. Maintaining a clear airway is essential to ensure that oxygen can reach the lungs and be circulated to vital organs. Without proper airway management, a patient's condition can quickly deteriorate due to hypoxia, leading to severe complications or even death. Therefore, assessing and securing the airway is the priority in the initial management of an unconscious patient to maintain adequate oxygenation and ventilation. Monitoring the respiration rate, depth, and effort is crucial to identify any signs of respiratory distress or failure that require immediate intervention. Once the airway and breathing are addressed, further assessments related to neurological function and sensory responses can be conducted.

Correct Answer: A

Rationale: Playing peek-a-boo is an appropriate play activity for a 7-month-old infant to encourage visual stimulation. By engaging in peek-a-boo, infants can improve their visual tracking skills, focus, and attention. The sudden appearance and disappearance of faces during the game can captivate the baby's attention and help develop their visual processing abilities. Additionally, playing peek-a-boo can foster social interaction, bonding, and trust between the infant and caregiver, contributing to the baby's overall development and well-being.

Correct Answer: B

Rationale: The correct administration time frame for a dose of parenteral ampicillin after it has been mixed is within 4 hours. This is based on the stability and compatibility of ampicillin when it is mixed and prepared for injection. Beyond 4 hours, the effectiveness and safety of the medication may be compromised due to potential degradation or contamination. It is crucial for healthcare providers to adhere to the recommended administration time frame to ensure the patient receives the full therapeutic benefits of the medication and to prevent any negative outcomes associated with the degradation of the drug.

Correct Answer: B

Rationale: Peer interactions are crucial during adolescence; having friends visit helps him feel connected and 'normal.'