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 D
Explanation
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.
Correct Answer is D
Explanation
Rationale:
A) Taking rectal temperatures may increase the risk of infection and is not typically recommended during chemotherapy.
B) Live vaccines such as MMR are generally contraindicated during chemotherapy due to the risk of vaccine-related complications in immunocompromised individuals.
C) Going to the park may expose the child to environmental pathogens and is not recommended during chemotherapy.
D) Inspecting the inside of the child's mouth for sores is important for early detection of oral mucositis, a common side effect of chemotherapy that can increase the risk of infection.
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