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 ["A","C","E"]
Explanation
A. The DTaP vaccine is recommended at 15-18 months, so it would be appropriate to administer it to a 1-year-old child.
B. The rotavirus vaccine is typically given earlier, before the child reaches 1 year of age.
C. The varicella (chickenpox) vaccine is given between 12-15 months of age, so it is appropriate for a 1-year-old.
D. The HPV vaccine is usually administered starting at age 11-12 years, not at 1 year.
E. The MMR (measles, mumps, rubella) vaccine is recommended between 12-15 months of age, making it appropriate for a 1-year-old.
Correct Answer is D
Explanation
A. Positioning the infant on the abdomen is contraindicated after cleft lip repair because it could put pressure on the surgical site, risking injury or dehiscence.
B. Offering a pacifier is not advised as it could disrupt the surgical site and delay healing.
C. Ibuprofen is not typically recommended for infants younger than 6 months due to the risk of adverse effects; acetaminophen is usually preferred for pain management in this age group.
D. Encouraging the parents to rock the infant provides comfort and soothes the baby without risking harm to the surgical site. Parental involvement also helps with bonding and emotional support during recovery.
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