The caregiver of an infant keeps removing the pulse oximetry sensor claiming it’s too tight on the baby. Which response should the nurse prioritize in addressing this situation?

Place the probe of the oximeter on the child’s chest and secure it with tape.

Explain that pulse oximetry is done to detect respiratory retractions.

Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin.

Ensure the oximeter probe site is checked every 8 hours for possible reactions.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing the probe on the chest is not a standard pulse oximetry site and yields inaccurate readings. Explaining the device’s purpose addresses the caregiver’s concern, making this ineffective and incorrect compared to educating about the sensor’s role in monitoring the infant’s oxygen levels.

Choice B reason: Pulse oximetry measures oxygen saturation, not respiratory retractions, which are observed visually. Explaining its true purpose reassures the caregiver, making this inaccurate and incorrect compared to clarifying the device’s function to address concerns about the sensor’s use on the infant.

Choice C reason: Explaining that pulse oximetry measures oxygen saturation clarifies its importance, reassuring the caregiver about its necessity and addressing tightness concerns. This aligns with pediatric nursing education principles, making it the prioritized response to ensure compliance with monitoring the infant’s respiratory status.

Choice D reason: Checking the probe site every 8 hours prevents skin issues but doesn’t address the caregiver’s concern about tightness. Explaining the device’s purpose promotes understanding, making this secondary and incorrect compared to educating to maintain the sensor’s use on the infant.

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Correct Answer is B

Explanation

Choice A reason: Walking backwards heel-to-toe requires advanced balance typically mastered closer to age 5 or 6. A 4-year-old can hop on one foot, a gross motor skill achievable by this age, making this too complex and incorrect for the preschooler’s developmental stage during the assessment.

Choice B reason: Hopping on one foot is a gross motor skill typically mastered by age 4, reflecting balance and coordination development. This aligns with pediatric developmental milestones, making it the correct activity a 4-year-old preschooler can successfully accomplish during a well-child gross motor assessment.

Choice C reason: Riding a bicycle, especially without training wheels, is typically achieved around age 5-6, requiring advanced coordination. A 4-year-old can hop on one foot, making this too advanced and incorrect for the gross motor skills expected at this age in a well-child visit.

Choice D reason: Jumping rope demands complex coordination and strength, typically mastered after age 6. A 4-year-old can hop on one foot, a simpler skill, making this incorrect, as jump rope is beyond the gross motor capabilities of a preschooler at this developmental stage.

A. An electric heating pad B. Towels dampened and heated in the microwave C. A hot water bottle D. Towels dampened with hot water

Correct Answer is D

Explanation

Choice A reason: An electric heating pad provides dry heat, not moist heat, which is needed for deeper tissue penetration and comfort. Towels dampened with hot water deliver moist heat effectively, making this incorrect for the caregiver’s instruction on providing the recommended therapy at home for the child.

Choice B reason: Microwave-heated towels risk uneven heating and burns, making them unsafe for moist heat application. Towels dampened with hot water ensure controlled, safe moist heat, making this unreliable and incorrect for the caregiver’s home application of moist heat therapy as recommended.

Choice C reason: A hot water bottle provides dry heat, not moist, as it does not involve dampness. Towels dampened with hot water meet the moist heat requirement, making this incorrect, as it fails to deliver the specific type of heat therapy recommended for the child’s home care.

Choice D reason: Towels dampened with hot water provide safe, effective moist heat, penetrating tissues and soothing the child’s condition as recommended. This method aligns with pediatric home care instructions, making it the correct choice for teaching the caregiver about moist heat application at home.

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The caregiver of an infant keeps removing the pulse oximetry sensor claiming it’s too tight on the baby. Which response should the nurse prioritize in addressing this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 4-year-old on a routine well-child visit. When assessing the gross motor skills of this preschooler, which activity will the nurse predict the child to be able to successfully accomplish?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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