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) Placing the child in a forward-facing car seat before the appropriate age and size increases the risk of injury.
B) Placing the child in the front seat, even in a rear-facing car seat, is not recommended due to the risk of airbag deployment.
C) Booster seats are used for older children who have outgrown their forward-facing car seats, but are not yet big enough to use the seat belt properly. Booster seats should be used until the child is at least 4 feet 9 inches tall and between 8 and 12 years old.
D) Placing the child in a rear-facing car seat until age 2 is recommended by safety guidelines to provide optimal protection for the child's head, neck, and spine.
Correct Answer is B
Explanation
Rationale:
A) This indicates a misunderstanding or lack of awareness regarding postoperative mobility expectations.
B) Beginning range-of-motion exercises on the first postoperative day indicates an understanding of the importance of early mobilization for recovery.
C) This may or may not be accurate depending on the individual's recovery progress, but it does not specifically demonstrate understanding of the teaching.
D) This indicates awareness of postoperative care but does not specifically address the immediate postoperative period.
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