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A nurse in an emergency department is caring for an infant.

Exhibits

The nurse on the pediatric unit is reviewing the infant's medical record immediately after receiving report from the emergency department nurse. Which of the following information requires immediate follow-up? Select all that apply.

Intake and output

Heart rate

Respiratory rate

Bowel sounds

Mucous membranes

Weight

Retractions

Lung sounds

Temperature

Oxygen saturation

Answer and Explanation

Correct Answer : A,B,C,G,H,I,J

A.   Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B.   Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C.   Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D.   Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E.   Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F.   Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G.   Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H.   Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I.   Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J.   Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Nutritionist. The toddler’s BMI (28) indicates obesity, necessitating a referral for nutritional counseling to guide healthier dietary practices.
B. Speech therapist. The toddler demonstrates age-appropriate speech development, including forming short sentences such as "want go home now."
C. Physical therapist. The toddler meets gross motor developmental milestones such as running, kicking, and throwing a ball.
D. Occupational therapist. The toddler’s ability to feed themselves using finger foods and utensils indicates appropriate fine motor skills.

A. The infant exhibits a fear of strangers. B. The infant understands the word "no". C. The infant has an absent grasp reflex. D. The infant rolls from their back to their abdomen.

Correct Answer is C

Explanation

A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is caring for a toddler in a pediatric clinic. Which of the following referrals should the nurse make?

Correct Answer is A

Explanation

A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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