A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?
BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F)
BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F)
BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F)
BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)
The Correct Answer is B
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Distended neck veins are not associated with pyloric stenosis.
B. A ridged abdomen is not typical of pyloric stenosis; rather, an olive-shaped mass may be palpated in the right upper quadrant.
C. Projectile vomiting is a hallmark sign of pyloric stenosis due to the obstruction at the pylorus, preventing food from passing into the small intestine.
D. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
Correct Answer is B
Explanation
A. Obtaining a blood culture is important but is not the immediate priority when a transfusion reaction is occurring.
B. Stopping the transfusion is the first step in managing a transfusion reaction to prevent further exposure to the allergen or irritant causing the symptoms.
C. Slowing the transfusion rate might not be sufficient if a reaction is occurring; stopping it is crucial.
D. Providing a diuretic is not relevant to the management of an acute transfusion reaction.
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