A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?
swer and explanation
An 18-month-old toddler who has a heart rate of 68/min
An adolescent who has a BP of 132/82 mm hg
A 3-month-old infant who has a respiratory rate of 36/min
The Correct Answer is B
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Having a vocabulary of 30 words is not a finding that should be reported to the provider for a 24-month-old toddler. By 24 months, most children can say 50 words or more.
Choice B rationale
Sleeping 11 to 12 hours per day is not a finding that should be reported to the provider for a 24-month-old toddler. This is a typical amount of sleep for a child this age.
Choice C rationale
Eating a large amount of food one day then very little the next is not a finding that should be reported to the provider for a 24-month-old toddler. Toddlers often have variable appetites, and it’s normal for them to eat more on some days and less on others.
Choice D rationale
Holding his breath when having a temper tantrum is a finding that should be reported to the provider for a 24-month-old toddler. While breath-holding spells can be a normal part of toddler behavior, they can also be a sign of an underlying medical condition. It’s important for the provider to evaluate this behavior to rule out any potential health concerns.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Placing gates at the top and bottom of stairs is an important safety measure for infants. This can prevent falls, which are a common cause of injury in this age group.
Choice B rationale
Ensuring the crib mattress is in the lowest position is another important safety measure. As infants grow and begin to sit, stand, and climb, a high mattress position can increase the risk of falls.
Choice C rationale
Removing labels from containers that contain toxic substances is not recommended. It’s important to keep these substances out of reach of children, and the labels provide important information about the contents and potential hazards.
Choice D rationale
Keeping toilet lids in the upright position is not recommended. Infants can be curious and may try to explore or play with water in the toilet, which can lead to accidents or injuries.
Choice E rationale
Selecting a toy chest that has a heavy, hinged lid is not recommended. This could pose a risk of injury if the lid were to close unexpectedly, and small fingers could get caught.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.