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 B
Explanation
A. Occasional incontinence in a 24-month-old toddler is developmentally appropriate and does not indicate abuse.
B. A spiral fracture in a 6-month-old infant is concerning for potential abuse and should be reported to authorities for further investigation.
C. Exposure to bedbugs and cellulitis, while requiring medical attention, does not necessarily indicate abuse.
D. Sibling rivalry is a common developmental occurrence and does not indicate abuse.
Correct Answer is []
Explanation
Condition:
Pyelonephritis: The presence of fever, frequent and painful urination, and costovertebral angle tenderness, along with the urinalysis findings (cloudy urine, leukocyte esterase, nitrites, WBCs) and elevated WBC count suggest an upper urinary tract infection, likely pyelonephritis.
Actions to Take:
Request prescription for antibiotics: Pyelonephritis is a bacterial infection that requires antibiotic treatment to prevent complications and resolve the infection.
Encourage increased fluid intake: This helps to flush bacteria from the urinary tract, reducing the concentration of bacteria in the urine and helping to relieve symptoms.
Parameters to Monitor:
Child’s report of urgency: This can help assess if the infection is affecting the lower urinary tract as well and track the effectiveness of treatment.
Urine odor: Foul-smelling urine can indicate ongoing infection or bacterial presence and can be an indicator of the effectiveness of the treatment.
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