A nurse is caring for a 2-month-old infant. Which of the following findings should the nurse report to the provider?
Blood pressure 95/58 mm Hg
Respiratory rate 18/min
Temperature 37.4° C (99.3°F)
Heart rate 160/min
The Correct Answer is B
A. A blood pressure of 95/58 mm Hg can be within an acceptable range for an infant and is not typically a cause for concern in a 2-month-old.
B. A respiratory rate of 18/min is abnormally low for a 2-month-old infant. Infants normally have a respiratory rate of about 30–60/min, and a low rate may indicate respiratory depression or other serious issues that should be reported promptly.
C. A temperature of 37.4° C (99.3°F) is within the expected range for an infant and does not indicate fever.
D. A heart rate of 160/min is within the normal range for a young infant, especially when awake or active.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will monitor the circulation in my baby's toes.” It is important to monitor the circulation in the toes of a child with serial casts, as the cast could cause pressure and affect blood flow. Checking for signs of poor circulation, such as color changes, temperature changes, or swelling, is crucial to ensure the cast is not too tight.
B. “I will give my baby ibuprofen for excessive crying.” Ibuprofen is not recommended for infants under 6 months of age, excessive crying should be evaluated to determine its cause. Administering ibuprofen without understanding the underlying issue could be inappropriate.
C. “My baby will need a calcium supplement with feedings.” Calcium supplements are not required for infants with clubfoot unless there is a specific indication, such as a dietary deficiency or underlying condition. Calcium is usually obtained through breast milk or formula.
D. “My baby will need to wear the casts for 4 to 6 months.” Serial casting for clubfoot treatment typically lasts longer than 4 to 6 months, depending on the severity of the condition and the child's response to treatment.
Correct Answer is B
Explanation
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
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