A nurse is collecting data from a 1-month-old infant who has just undergone a hernia repair. Which of the following findings should the nurse report to the provider?
Axillary temperature 37.4° C (99.3° F)
Apical pulse 155/min
Respiratory rate 40/min
Blood pressure 64/40 mm Hg
The Correct Answer is D
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A) Foods high in fiber are generally healthy and do not need to be avoided with lisinopril.
B) Lisinopril can increase potassium levels in the blood, so clients should avoid high- potassium foods to prevent hyperkalemia.
C) Foods high in vitamin K are typically associated with blood clotting and are not contraindicated with lisinopril.
D) Dairy products are not specifically contraindicated with lisinopril, although they should be consumed in moderation as part of a balanced diet.
Correct Answer is A
Explanation
Rationale:
A) Offering a pacifier can help soothe a fussy baby with colic.
B) Offering water in between feedings is not recommended for infants, especially at 1 month old, as it can interfere with proper feeding and increase the risk of water intoxication.
C) Placing a warm heating pad on the baby's abdomen is not recommended without specific guidance from a healthcare provider and can pose a risk of burns.
D) Allowing the baby to cry for 5 minutes before responding is not recommended for infants, as it can lead to increased stress and distress.
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