A nurse is monitoring the vital signs of a 6-year-old child following a surgical procedure. Which of the following findings should the nurse report to the provider?
Axillary temperature 37.3° C (99.1° F)
Respiratory rate 24/min
Heart rate 59/min
Blood pressure 96/58 mm Hg
The Correct Answer is C
A. An axillary temperature of 37.3° C (99.1° F) is within the normal range for a child and does not need to be reported.
B. A respiratory rate of 24/min is within the normal range for a 6-year-old child and does not need to be reported.
C. A heart rate of 59/min is slightly below the normal range for a 6-year-old and should be reported to the provider.
D. A blood pressure of 96/58 mm Hg is within the normal range for a 6-year-old child and does not need to be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mixing medication in a bottle of formula is not recommended as the infant may not finish the entire bottle, leading to incomplete dosage. It also changes the taste of the formula, which may cause feeding aversions.
B. Honey should not be given to infants under 1 year old due to the risk of botulism. It is not a suitable medium for mixing medication for young infants.
C. Placing the medication in an oral syringe allows for precise dosing and easy administration. It ensures that the infant receives the correct amount of medication.
D. Placing the medication in the back of the infant's throat using a dropper can cause gagging and aspiration. An oral syringe allows for better control and safer administration.
Correct Answer is C
Explanation
A. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.
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