A nurse is reviewing the medical record of a school-age child who was admitted for suspected physical maltreatment. Which of the following findings in the child's medical history should the nurse identify as a potential risk factor for physical maltreatment?

Answer: B. Reposition the probe every 2 hours.

Rationale:

• A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
• B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
• C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
• D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

• The nurse should also choose a clean and dry site for probe placement.
• The probe should be snug but not too tight.
• The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
• If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

The correct answer is choiceb. “Your baby will be placed in elbow restraints following surgery.”

Choice A rationale:

Giving a pacifier to a baby after cleft lip surgery is generally not recommended as it can put pressure on the surgical site and potentially disrupt the healing process.

Choice B rationale:

Elbow restraints are used to prevent the infant from touching or rubbing the surgical site, which helps in protecting the stitches and ensuring proper healing.

Choice C rationale:

Infants are usually allowed to have fluids by mouth soon after surgery, often within a few hours, to ensure they stay hydrated and to monitor their ability to swallow.

Choice D rationale:

Positioning the baby on their abdomen is not recommended as it can put pressure on the surgical site.Instead, the baby should be positioned on their back or side to avoid any pressure on the repaired lip