The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia?
Pulmonary function test
Pulse oximetry
Peak expiratory flow
Chest radiograph
The Correct Answer is B
A. Pulmonary function test: Pulmonary function tests measure lung volumes, capacities, and airflow to assess chronic respiratory conditions. They are not practical or rapid for assessing acute hypoxia in a child presenting with tachycardia and tachypnea.
B. Pulse oximetry: Pulse oximetry provides a noninvasive, immediate measurement of arterial oxygen saturation, allowing rapid detection of hypoxemia. It is highly useful in evaluating the extent of hypoxia in an acutely ill child and guiding supplemental oxygen therapy.
C. Peak expiratory flow: Peak expiratory flow monitoring measures the speed of exhalation, primarily used to monitor asthma control. It does not directly quantify oxygenation or hypoxia.
D. Chest radiograph: A chest X-ray can identify structural or pathological lung changes, such as pneumonia or atelectasis, but it does not provide direct or real-time information about oxygen saturation or the severity of hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Turn the patient to semi-Fowler position: Changing maternal position can sometimes relieve cord compression, but the presence of a pulsating umbilical cord indicates umbilical cord prolapse, which is an obstetric emergency requiring immediate intervention beyond positioning.
B. Call for immediate assistance to prepare for delivery: A pulsating cord suggests cord prolapse or imminent compromise, placing the fetus at risk for hypoxia. Immediate activation of the obstetric team is the priority to expedite delivery, typically by cesarean section if vaginal birth is not imminent.
C. Oxygen at 2 L/min: Administering oxygen may support fetal oxygenation but is secondary to urgent delivery. Oxygen alone cannot resolve cord compression or prevent fetal compromise.
D. Placement of a Foley catheter: Bladder emptying may help facilitate cesarean delivery, but it is not the initial priority. The urgent focus is on activating the team and preparing for immediate delivery to prevent fetal hypoxia.
Correct Answer is C
Explanation
A. Limit the amount of time the infant nurses on each breast: Shortening feeding sessions can lead to incomplete emptying of the breasts, increasing milk stasis and worsening mastitis. Adequate drainage is essential to reduce infection risk and promote healing.
B. Nurse the infant only on the unaffected breast until resolved: Avoiding the affected breast can lead to engorgement, further milk stasis, and prolonged infection. Continuing to feed from both breasts helps maintain milk flow and relieves pressure in the infected area.
C. Completely empty each breast at each feeding or use a pump: Full emptying of the breasts reduces milk stasis, which is a primary factor contributing to mastitis. Frequent and effective milk removal helps resolve inflammation, decreases bacterial proliferation, and supports ongoing lactation.
D. Wear a tight-fitting bra until lactation has ceased: Tight or restrictive bras can compress breast tissue, impair milk flow, and exacerbate mastitis. Loose, supportive bras are recommended to allow adequate drainage and comfort.
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