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A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?

A.

An adolescent who has a BP of 132/82 mm Hg

B.

A 3-month-old infant who has a respiratory rate of 30/min

C.

An 18-month-old toddler who has a heart rate of 68/min

D.

A school-age child who has a rectal body temperature of 37.3° C (99.1° F)

Answer and Explanation

The Correct Answer is C

A.    A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.


B.    A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected  (typically 25-40 breaths per minute). 
 
C.    A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D.    A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.


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Related Questions

Correct Answer is B

Explanation

A. A preschool-age child is not expected to give a logical explanation for death. They may not fully understand the concept of death in the same way an older child or adult does.

B. Correct. It is common for preschool-age children to be curious about what happens to the body after death. This curiosity is an age-appropriate response to death.

C. A preschool-age child may not fully grasp the concept of death as permanent. They may have limited understanding of the irreversibility of death.

D. Feeling responsible for a sibling's death would be an inappropriate and potentially concerning response for a preschool-age child. It may indicate a need for further assessment and support.

Correct Answer is C

Explanation

A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.


B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).

C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.

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