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 D
A. Blood pressure 95/58 mm Hg: A blood pressure of 95/58 mm Hg is within a normal range for a 2-month-old infant. The typical blood pressure for infants in this age group can range from 65/45 mm Hg to 105/70 mm Hg, depending on their overall health.
B. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is low for a 2-month-old. The normal range for infants at this age is between 30 to 60 breaths per minute, so a rate of 18 is too slow and may indicate respiratory distress that should be assessed further.
C. Temperature 37.4° C (99.3°F): A temperature of 37.4°C (99.3°F) is within the normal range for a 2-month-old infant. Normal body temperature for infants typically ranges between 36.5°C to 37.5°C (97.7°F to 99.5°F).
D. Heart rate 160/min: The normal resting heart rate for a 2-month-old infant typically ranges from 100-180 beats per minute (bpm) when awake. A heart rate of 160/min is within this expected range for an infant and does not indicate an abnormality that needs to be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Complete the following sentence by using the lists of options.
The nurse should recommend to
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.
Correct Answer is C
Explanation
A. Prolonged crying: Prolonged crying can occur after an immunization, especially in infants, but it is generally not an immediate cause for concern unless accompanied by other symptoms such as difficulty breathing or skin changes.
B. Temperature 37.7° C (99.9° F): A mild fever is a common side effect after immunizations and is usually not a cause for immediate concern. A temperature of 37.7°C (99.9°F) is within a normal range and typically resolves on its own.
C. Hives on the child's neck: Hives (urticaria) can indicate an allergic reaction, which could potentially be a serious response to the immunization. An allergic reaction requires immediate attention and intervention, as it may progress to more severe symptoms such as difficulty breathing or anaphylaxis.
D. Redness at the injection site: Redness at the injection site is a common and expected reaction following an immunization. It is generally not a cause for concern unless it is accompanied by severe swelling, pain, or other signs of infection.