A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?
An adolescent who has a BP of 132/82 mm Hg
A 3-month-old infant who has a respiratory rate of 30/min
An 18-month-old toddler who has a heart rate of 68/min
A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Jacket restraints are typically used to secure a child's arms during procedures. They are not specifically designed for venipuncture in infants.
B. Elbow restraints are used to secure the child's elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
C. The mummy restraint is specifically designed to secure an infant's arms during venipuncture. It wraps the arms snugly, allowing access to the veins while minimizing movement.
D. Mitten restraints are used to prevent the child from manipulating equipment or accessing areas that should be restricted. They are not designed for venipuncture procedures.
Correct Answer is A
Explanation
A. This is the correct intervention. Encouraging the toddler to use an incentive spirometer helps promote lung expansion and prevent atelectasis (collapsed lung tissue), which is
important for postoperative respiratory function.
B. Placing a cooling blanket on the toddler is not a standard intervention following routine surgery. It's important to monitor the toddler's temperature and use appropriate measures if they experience hyperthermia.
C. Administering IV dantrolene sodium is used for the treatment of malignant hyperthermia, a rare but life-threatening reaction to certain medications used during anesthesia. It is not a routine postoperative intervention.
D. Aspirin is generally not recommended for pain relief in children due to the risk of Reye's syndrome. Other pain management options, such as acetaminophen or ibuprofen, are typically used for postoperative pain in children.
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