A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder.
Which of the following factors related to family dynamics should the nurse include in the teaching?

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

Choice A reason:Asking the mother if any visitors were expected to arrive is important for gathering information but does not directly address the immediate concern of the potentially missing newborn. It should not be the first action.

Choice B reason:Matching ID bands of all infants and mothers on the unit is the correct first action. It is a critical step in ensuring the safety and security of all infants and mothers, helping to prevent any potential mix-ups or missing infants.

Choice C reason:Determining if the newborn is in the nursery is an important step, but it should not precede the matching of ID bands. The first action should be more immediate and comprehensive in ensuring the safety of all patients on the unit.

Choice D reason:Activating the lockdown procedure is a response to a confirmed security threat. In this scenario, the primary concern is the potential misplacement of an infant, not a confirmed security threat, so this should not be the first action taken.