A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
The pulse oximeter might not be accurate during times of excessive movement.
We will notify the doctor if the pulse oximeter consistently reads 100%.
We will rotate the probe of the pulse oximeter every 24 hours.
The probe of the pulse oximeter can be applied to a finger or a toe.
The Correct Answer is C
Choice A reason: This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.
Choice B reason: A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.
Choice C reason: The probe placement does not need to be rotated every 24 hours. Once the probe is correctly positioned (usually on a finger or toe), it can remain in place for continuous monitoring without needing frequent adjustments.
Choice D reason: This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The child has signs of dehydration and hypovolemic shock, such as vomiting, melena, abdominal pain, and weak pedal pulses. Dehydration is a loss of fluid and electrolytes from the body, which can result from gastroenteritis. Hypovolemic shock is a life-threatening condition that occurs when the blood volume is too low to maintain adequate perfusion and oxygen delivery to the vital organs.
Choice B reason: The child does not have signs of peritonitis and septic shock, such as fever, chills, rigors, tachycardia, hypotension, and abdominal rigidity. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity and organs. Septic shock is a severe infection that causes systemic inflammatory response syndrome and organ dysfunction.
Choice C reason: The child does not have signs of pancreatitis and cardiogenic shock, such as elevated serum amylase and lipase, jaundice, dyspnea, crackles, and chest pain. Pancreatitis is an inflammation of the pancreas, an organ that produces digestive enzymes and hormones. Cardiogenic shock is a failure of the heart to pump enough blood to meet the body's needs.
Choice D reason: The child does not have signs of peptic ulcer and anaphylactic shock, such as hematemesis, dyspepsia, urticaria, angioedema, and wheezes. Peptic ulcer is a sore in the lining of the stomach or duodenum, caused by factors such as Helicobacter pylori infection, NSAIDs, or stress. Anaphylactic shock is a severe allergic reaction that causes bronchoconstriction, vasodilation, and hypotension.
Correct Answer is A
Explanation
Choice A reason: This is the best option to prevent reflux, as it allows gravity to help keep the stomach contents down. The nurse should advise the parent to keep the baby upright for at least 30 minutes after each feeding.
Choice B reason: Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.
Choice C reason: Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.
Choice D reason: Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today