A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

Respiratory rate 68/min.

BP 64/42 mm Hg.

Axillary temperature 36.6° C (97.9° F).

Apical heart rate 124/min.

Answer and Explanation

The Correct Answer is A

This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.

Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.

Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).

Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.

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Correct Answer is B

Explanation

“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.

Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.

Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.

Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.

Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.

A. Proteinuria. B. Hypolipidemia. C. Hyperalbuminemia. D. Increased hemoglobin.

Correct Answer is A

Explanation

Proteinuria is the presence of excess protein in the urine, which is a hallmark of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that causes increased permeability of the glomerular basement membrane, leading to loss of protein and other substances in the urine.

Choice B is wrong because hypolipidemia is a low level of lipids in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hyperlipidemia, which is a high level of lipids in the blood, due to increased synthesis and decreased clearance of lipoproteins.

Choice C is wrong because hyperalbuminemia is a high level of albumin in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hypoalbuminemia, which is a low level of albumin in the blood, due to loss of albumin in the urine and decreased synthesis by the liver.

Choice D is wrong because increased hemoglobin is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome can cause anemia, which is a low level of hemoglobin in the blood, due to loss of iron and erythropoietin in the urine and decreased production of red blood cells by the bone marrow.

Normal ranges for proteinuria are less than 150 mg per day or less than 10 mg per deciliter on a random urine sample. Normal ranges for serum lipids are total cholesterol less than 200 mg per deciliter, LDL cholesterol less than 100 mg per deciliter, HDL cholesterol more than 40 mg per deciliter for men and more than 50 mg per deciliter for women, and triglycerides less than 150 mg per

deciliter. Normal ranges for serum albumin are 3.5 to 5.0 grams per deciliter.

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A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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