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
Explanation
A. Puberty might be considered delayed if there are no scrotal changes by the age of 11 years, as testicular enlargement is one of the earliest signs of puberty in boys.
B. Growth spurts typically occur early in puberty, not towards the end.
C. Changes in voice occur later in puberty, not at the beginning.
D. Gynecomastia (breast tissue development) commonly occurs during early puberty rather than late puberty and is usually temporary.
Correct Answer is C
Explanation
A. Hypertension is not typical for nephrotic syndrome; instead, nephrotic syndrome often presents with low blood pressure or normal blood pressure.
B. Polyuria is more commonly associated with conditions like diabetes mellitus rather than nephrotic syndrome, which typically presents with reduced urine output.
C. Facial edema is a common finding in nephrotic syndrome due to fluid retention and is often noticeable in the periorbital area.
D. Smokey brown urine is indicative of hematuria or glomerulonephritis, not nephrotic syndrome.
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