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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for A: If the child can describe what frightened them, this would be more consistent with nightmares. Nightmares often involve the ability to recall details of the bad dream, whereas sleep terrors are typically associated with no memory of the event.
Rationale for B: Children with sleep terrors generally do not fully awaken and can usually go back to sleep immediately. This is a key distinction between sleep terrors and nightmares, where the child remains distressed for some time and may be hesitant to fall back asleep.
Rationale for C: Becoming fully awake and in a panic is more characteristic of nightmares, where the child may wake up terrified and struggle to calm down, unlike sleep terrors where they do not fully awaken.
Rationale for D: A child with nightmares is often easily comforted by the presence of a parent. In contrast, children with sleep terrors are difficult to comfort because they are not fully awake and may not respond to soothing efforts.
Correct Answer is D
Explanation
Rationale:
A. Skin turgor assessment is important in assessing dehydration, but the priority is addressing the tachycardia first.
B. Potassium level is important in managing electrolyte imbalance in gastroenteritis, but the priority is addressing the elevated heart rate first.
C. Capillary refill is an important assessment for circulation, but the priority is addressing the elevated heart rate first.
D. The elevated heart rate (tachycardia) indicates increased workload on the heart, likely due to dehydration or other complications of gastroenteritis. This requires immediate attention to stabilize the infant's condition.
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