A nurse responds to an order to place an infant in an overhead radiant heater. Which of the following are recommended guidelines the nurse should follow?

Correct Answer: B

Rationale: Radiant heaters regulate infant temperature safely. A bony area probe is incorrect; it's placed on soft tissue (e.g., abdomen). Warming blankets first ensures comfort and gradual warming, a recommended step. An uncovered probe is true but less critical than B. Manual adjustment every 15 minutes risks instability; servo-control is preferred. Choice B is correct as pre-warming blankets aligns with guidelines (e.g., AAP) to prevent cold stress, enhancing safety and effectiveness in neonatal thermoregulation.

Correct Answer: A

Rationale: Vital signs measure essential physiological functionstemperature, pulse, respiration, blood pressure, and oxygen saturationreflecting the body's basic operations . Urination frequency isn't a vital sign, though it's monitored in specific contexts. Weight and height are anthropometric, not vital signs. BMI is a calculated health indicator, not a direct measurement. Choice A is correct, aligning with nursing fundamentals defining vital signs as core indicators of life-sustaining processes, routinely assessed to evaluate health status and detect deviations requiring intervention.

Correct Answer: C

Rationale: BP readings show systolic (top, ventricular contraction) and diastolic (bottom, relaxation) pressures , in mmHg. Oxygen saturation and pulse are separate. Diastolic over systolic reverses order. Millimeters and mercury is the unit, not the terms. Choice C is correct, per standard BP notation (e.g., 120/80 mmHg), a foundational nursing concept for documenting cardiac workload.

Correct Answer: A

Rationale: The best response in this scenario is option A) Assess the patient's apical pulse to obtain the heart rate. This is the correct choice because in a situation where obtaining the heart rate from the right radial pulse is difficult, the apical pulse provides an accurate alternative. The apical pulse is auscultated at the apex of the heart using a stethoscope, allowing for an accurate assessment of the heart rate. Option B) Obtain the heart rate from right and left radial sites is incorrect because if the right radial pulse is difficult to palpate, it is likely that the left radial pulse would also be challenging to locate. Option C) Obtain the heart rate using the oximeter probe is not the most appropriate choice in this situation because the oximeter probe measures oxygen saturation, not heart rate. Option D) Perform a complete assessment of all pulses is not necessary in this scenario as the focus is on obtaining the heart rate accurately. A complete pulse assessment may be indicated for a different purpose, but in this case, assessing the apical pulse is the most direct and effective method. Educationally, understanding alternative methods for assessing heart rate is crucial for healthcare providers to ensure accurate monitoring of vital signs postoperatively. Practicing assessment techniques helps develop clinical reasoning skills and ensures high-quality patient care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Use oxygen cautiously in this patient. This is because the patient has chronic lung disease and still smokes, which puts them at risk for retaining carbon dioxide (CO2) due to a condition called CO2 retention. Administering high levels of oxygen (Option A) can suppress the patient's respiratory drive, leading to further CO2 retention and potential respiratory failure. Placing a paper bag over the patient's face (Option C) can worsen the situation by increasing CO2 levels. Administering CO2 via mask (Option D) is not a standard practice in this situation and can be harmful. Educationally, this question highlights the importance of understanding the physiological principles underlying oxygen therapy in patients with chronic lung disease. It emphasizes the need for nurses to assess and monitor patients carefully, especially those with pre-existing respiratory conditions, to prevent potential complications associated with oxygen therapy. By choosing the correct answer, nurses can provide safe and effective care tailored to the individual patient's needs.