While caring for a 1-year-old child, the nurse notes that the child's oxygen saturation level is at 90%. Which action would the nurse take next?

Notify the health care provider

Immediately take the child's blood gas

Give oxygen via face mask a 2 liters per minute

Assess the child's respiratory status

Answer and Explanation

The Correct Answer is D

A. Notify the health care provider: While notifying the healthcare provider may be necessary if the child's oxygen saturation does not improve, the first step is to assess the child's respiratory status to determine if immediate intervention is needed.

B. Immediately take the child's blood gas: A blood gas may be helpful later, but the priority should be to assess the child's respiratory status and address any immediate concerns with oxygenation before proceeding with more invasive assessments.

C. Give oxygen via face mask at 2 liters per minute: Administering oxygen may be necessary, but the nurse should first assess the child's respiratory status to determine if oxygen supplementation is required and the appropriate delivery method.

D. Assess the child's respiratory status: The most appropriate action is to assess the child's respiratory status. This includes checking for signs of distress, work of breathing, and other factors that could help determine the cause of the low oxygen saturation and guide the appropriate intervention.

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Correct Answer is B

Explanation

A. Cerebrovascular accident: A cerebrovascular accident (stroke) is not commonly associated with surgery for myelomeningocele. While neurological complications can occur, a stroke is not a primary concern in the immediate postoperative period for this condition.

B. Hydrocephalus: Hydrocephalus is a common condition in infants with myelomeningocele. It occurs due to the impaired flow of cerebrospinal fluid (CSF) as a result of the neural tube defect, leading to increased pressure within the ventricles of the brain.

C. Dehydration: While dehydration is a concern for many surgical patients, it is not specifically related to surgery for myelomeningocele. The primary postoperative concerns would involve the neurological status, including the presence of hydrocephalus.

D. Urinary tract infection: Although urinary tract infections can occur in infants, especially in those with neural tube defects, they are not the most immediate concern following surgery for myelomeningocele. The focus is more on monitoring for neurological complications.

A. Diffuse buccal erythema without discharge B. Oral pruritus C. Mucopurulent sputum D. Presence of a white membrane on tongue

Correct Answer is D

Explanation

A. Diffuse buccal erythema without discharge: Diffuse erythema in the mouth is a common symptom of irritation or inflammation but is not characteristic of oral candidiasis (thrush). Thrush typically presents with white, curd-like lesions rather than just erythema.

B. Oral pruritus: Oral itching or pruritus is not typically associated with oral candidiasis in infants. Thrush is usually more painful or uncomfortable for the infant rather than itchy, and the hallmark symptom is the presence of white patches.

C. Mucopurulent sputum: Mucopurulent sputum may suggest a respiratory infection or another illness but is not associated with oral candidiasis. Thrush primarily affects the mouth and does not cause mucous or purulent sputum.

D. Presence of a white membrane on tongue: The most characteristic sign of oral candidiasis (thrush) in infants is the presence of white, cottage cheese-like lesions or a white membrane on the tongue, gums, or inside of the cheeks. These lesions are caused by the overgrowth of the yeast Candida albicans.

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While caring for a 1-year-old child, the nurse notes that the child's oxygen saturation level is at 90%. Which action would the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For which condition would the nurse commonly assess in an infant following surgery for a myelomeningocele?

Correct Answer is B

Explanation

Infants or children receiving antibiotics may develop oral candidiasis (thrush). Which finding suggests that an infant has thrush?

Correct Answer is D

Explanation

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