A nurse is caring for a 4-month-old infant in the outpatient setting.

Exhibits

Which of the following should the nurse identify as unexpected findings? Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Body system	Findings
Vital Signs	Temperature 36.9°C (98.4° F) Heart rate 162/min Respiratory rate 28/min Oxygen saturation 97% on room air
Gastrointestinal	Also spits up after every feeding, sometimes forcefully. Infant is formula fed and recently began refusing some feedings. Bowel sounds normoactive. Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus. Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz).

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.

A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. While an infant cannot consent, IV antibiotics are considered a routine medical treatment. General consent for treatment is usually signed upon admission to the hospital, which covers standard nursing interventions like starting an IV or administering prescribed medications. Specific informed consent forms are typically reserved for higher-risk procedures (surgeries, blood transfusions, etc.).
C. In most jurisdictions, minors can provide their own consent for medically emancipatedconditions. These typically include prenatal care, contraception, testing and treatment for STIs, and substance abuse treatment. The nurse would not need to obtain consent from a guardian in this specific context to protect the minor's privacy and access to care.

D. A chest x-ray is a non-invasive diagnostic procedure. Similar to the administration of medications, these are covered under the general consent for treatment signed at the time of admission. They do not require a separate, formal informed consent document for each individual imaging study.