A nurse is caring for a toddler.
The nurse’s observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next?

The correct answer is Choice A

Choice A rationale: Iron 38 mcg/dL is below the normal range for children (50-120 mcg/dL). Low iron levels can indicate iron deficiency anemia, which requires medical evaluation and intervention to prevent complications such as developmental delays and decreased immunity.

Choice B rationale: RBC 4.9 million/mm is within the normal range for children (4.0-5.5 million/mm). This value does not indicate any abnormalities and does not require reporting to the provider. RBC count helps in assessing the overall red blood cell health and oxygen-carrying capacity.

Choice C rationale: WBC 10,000 cells/mm is within the normal range for children (5,000-10,000 cells/mm). This value is considered normal and does not indicate an infection or other condition needing immediate attention. WBC count is critical for evaluating the immune system's response to infection.

Choice D rationale: Lead 2 mcg/dL is within the acceptable range for children. The Centers for Disease Control and Prevention (CDC) considers lead levels less than 5 mcg/dL to be acceptable. Lead exposure can harm children's development, but this level does not necessitate immediate reporting

Choice A rationale

Standing directly in front of a patient who has a history of anger and aggression can be perceived as threatening and may escalate the situation.

Choice B rationale

Knowing the layout of the facility can help the nurse to plan for safe exits or to put barriers between themselves and the patient if needed.

Choice C rationale

Bringing security for all patient interactions can escalate the situation and should only be done if there is a clear threat to safety.

Choice D rationale

Providing immediate verbal feedback for escalating behavior can help to de-escalate the situation and reassure the patient.

Choice E rationale

Avoiding wearing necklaces during patient care can reduce the risk of injury to the nurse.