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.
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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. Insulin should not be stored in the freezer, as freezing it can cause it to lose potency. Unopened insulin should be stored in the refrigerator.
B. The target blood glucose for a school-age child with type 1 diabetes is typically between 90 and 130 mg/dL, but this answer does not directly relate to management practices.
C. Insulin requirements may actually increase during illness, and skipping insulin can lead to dangerous hyperglycemia or diabetic ketoacidosis.
D. Eating a snack before physical activity is crucial to prevent hypoglycemia, especially in a child with type 1 diabetes. This response shows an understanding of managing blood glucose during exercise.
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