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 A
Explanation
Choice A reason: The vastus lateralis is the preferred site for IM injections in infants, as it is well-developed, has minimal nerves and vessels, and accommodates safe volumes. This aligns with pediatric nursing injection guidelines, making it the best choice for a 3-month-old receiving an antibiotic intramuscularly.
Choice B reason: The deltoid muscle is underdeveloped in a 3-month-old, with insufficient muscle mass for safe IM injections. The vastus lateralis is safer and more developed, making this incorrect, as the deltoid risks injury or inadequate drug absorption in infants receiving intramuscular injections.
Choice C reason: The dorsogluteal muscle is avoided in infants due to proximity to the sciatic nerve and underdeveloped gluteal mass, risking nerve damage. The vastus lateralis is safer, making this incorrect for a 3-month-old, as it poses significant safety concerns for IM antibiotic injections.
Choice D reason: The ventrogluteal muscle is safe in older children but less accessible in infants due to small muscle mass and positioning challenges. The vastus lateralis is preferred for its accessibility and safety, making this incorrect for a 3-month-old’s IM antibiotic injection in clinical practice.
Correct Answer is A
Explanation
Choice A reason: Reassuring the sister while attending to the child and involving her in interventions reduces her anxiety, stabilizing the 5-year-old’s emotional state. This aligns with pediatric emergency care principles, making it the best initial action to manage the escalating anxiety in the emergency room.
Choice B reason: Asking the sister to leave may increase her distress and isolate the child, worsening his anxiety. Reassuring and involving her is more supportive, making this counterproductive and incorrect compared to the nurse’s role in calming both the caregiver and child effectively.
Choice C reason: Reassuring the child about his sister’s nerves doesn’t address her anxiety, which is escalating his distress. Involving the sister in care reduces both anxieties, making this insufficient and incorrect compared to the nurse’s priority of stabilizing the emotional environment in the ER.
Choice D reason: Asking the sister to calm down may heighten her distress, as she’s already hysterical, and doesn’t offer support. Reassuring and involving her helps both, making this ineffective and incorrect compared to the nurse’s action to reduce anxiety for the child and caregiver.
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