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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Picking up the child without assessment risks disrupting a potentially critical condition, as quiet lying may indicate pain or altered consciousness. Checking consciousness and pain ensures safety, making this premature and incorrect compared to prioritizing a thorough evaluation of the child’s quiet state.
Choice B reason: Leaving the child in a flexed position assumes no issue without assessing consciousness or pain, which quiet behavior may mask. Evaluating the child’s status is critical, making this passive and incorrect compared to actively checking for underlying issues in the child’s quiet presentation on the bed.
Choice C reason: Checking the level of consciousness and pain scale determines if the child’s quietness indicates distress, pain, or neurological issues, ensuring appropriate care. This aligns with pediatric assessment protocols, making it the correct action to address the child’s condition lying quietly on the bed.
Choice D reason: Assuming the child is sleeping on the parent’s lap is incorrect, as the child is on the bed, and quietness may indicate distress. Assessing consciousness and pain is essential, making this inaccurate and incorrect compared to evaluating the child’s true condition in this scenario.
Correct Answer is C
Explanation
Choice A reason: Having the nurse do everything may disrupt the toddler’s trust in parents, hindering adaptation. Following home routines provides familiarity, making this counterproductive and incorrect compared to maintaining continuity to ease the toddler’s transition from home to the hospital environment.
Choice B reason: Telling a toddler expectations assumes cognitive understanding beyond their developmental stage, potentially increasing anxiety. Home routines offer comfort, making this less effective and incorrect compared to the nurse’s focus on familiarity to support the toddler’s hospital adaptation process.
Choice C reason: Following home routines maintains familiarity, reducing stress and aiding a toddler’s adaptation to the hospital. This aligns with pediatric psychosocial care principles, making it the most beneficial action for the nurse to implement to ease the toddler’s transition from home to hospital.
Choice D reason: Allowing a toddler to dictate actions disregards necessary medical routines, potentially compromising care and safety. Home routines provide structure, making this impractical and incorrect compared to the nurse’s role in maintaining familiarity to support the toddler’s hospital adaptation.
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