A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
The pulse oximeter might not be accurate during times of excessive movement.
We will notify the doctor if the pulse oximeter consistently reads 100%.
We will rotate the probe of the pulse oximeter every 24 hours.
The probe of the pulse oximeter can be applied to a finger or a toe.
The Correct Answer is C
Choice A reason: This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.
Choice B reason: A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.
Choice C reason: The probe placement does not need to be rotated every 24 hours. Once the probe is correctly positioned (usually on a finger or toe), it can remain in place for continuous monitoring without needing frequent adjustments.
Choice D reason: This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as the child will not have normal bowel movements immediately after the initial surgery. The surgery involves removing the affected part of the colon and creating a temporary ostomy, which is an opening in the abdomen that allows stool to pass into a bag. The child will need a second surgery to reconnect the bowel and close the ostomy.
Choice B reason: This statement is incorrect, as the child will not need a feeding tube after the initial surgery. The child will be able to eat and drink normally but may need to follow a low-fiber diet to avoid constipation and bowel obstruction.
Choice C reason: This statement is incorrect, as the child will not need a urinary catheter after the initial surgery. The child will be able to urinate normally but may need to drink plenty of fluids to prevent dehydration and urinary tract infections.
Choice D reason: This statement is correct, as the child's ostomy is only temporary and will be closed in a second surgery. The parent should be glad that the child will eventually have a normal bowel function and appearance. The parent should also learn how to care for the ostomy and change the bag until the second surgery.
Correct Answer is D
Explanation
Choice A reason: Drooling is not a sign of hemorrhage, but rather a sign of difficulty swallowing or breathing. Drooling may occur after a tonsillectomy due to throat pain or swelling, but it does not indicate bleeding.
Choice B reason: Poor fluid intake is not a sign of hemorrhage, but rather a sign of dehydration or nausea. Poor fluid intake may occur after a tonsillectomy due to throat pain or fear of swallowing, but it does not indicate bleeding.
Choice C reason: Increased pain is not a sign of hemorrhage, but rather a sign of inflammation or infection. Increased pain may occur after a tonsillectomy due to tissue damage or healing, but it does not indicate bleeding.
Choice D reason: Frequent swallowing is a sign of hemorrhage, as it indicates that the child is trying to clear blood from the throat. Frequent swallowing may occur after a tonsillectomy due to bleeding from the surgical site or a ruptured blood vessel.
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