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)

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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Correct Answer is A

Explanation

A. A toddler's repeated refusal to let a nurse perform a routine medical assessment may indicate fear or discomfort around adults, which could be a potential indicator of child abuse or neglect.

B. A mother's hesitation to comfort her 6-month-old infant may be due to various reasons, such as cultural differences, lack of confidence, or personal preferences. It is not necessarily indicative of child abuse.

C. Bruises on a toddler's knees are a common finding in active children who are learning to walk and explore their environment. While bruises should always be assessed, they are not automatically indicative of child abuse.

D. An 8-month-old infant crying when a parent leaves the room is a normal separation anxiety response for an infant of this age and is not indicative of child abuse. This behavior is part of normal infant development.

A. Supine B. Semi-Fowler's C. Lateral D. Prone

Correct Answer is C

Explanation

A. Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

B. A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

C. Correct. Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.

D. Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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