A nurse is obtaining a 4-month-old infant's vital signs. The infant's heart rate is 190/min, and her temperature is 40° C (104° F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate response by the nurse?
"As your baby begins to fall asleep, her heart rate will decrease."
"Your baby's heart is beating fast in an attempt to cool down the body."
"This is within the expected range for your baby."
"The fever is causing an increase in your baby's heart rate."
The Correct Answer is D
A. "As your baby begins to fall asleep, her heart rate will decrease. This statement may be true in a general sense, but it does not address the parent's specific concern about the cause of tachycardia in the context of fever. It's vague and dismissive of the elevated temperature.
B. "Your baby's heart is beating fast in an attempt to cool down the body." While increased heart rate can be part of the body's response to fever, the primary reason is not to "cool down" the body but to increase metabolism and circulation. This explanation is not entirely accurate.
C. "This is within the expected range for your baby." A heart rate of 190/min at rest is above the normal range for a 4-month-old, especially in the context of fever. Normal resting heart rate for this age is approximately 100-160 bpm. This response is inaccurate and misleading.
D. "The fever is causing an increase in your baby's heart rate." Fever increases metabolic demand, which leads to an elevated heart rate (tachycardia). This is a clear, accurate, and appropriate explanation for the parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bradycardia: Tachycardia is more likely due to pain or hypoxia.
B. Constipation: Not a hallmark feature of vaso-occlusive crisis.
C. Pain: Vaso-occlusive crises are characterized by severe pain due to ischemia caused by sickled red blood cells obstructing blood flow.
D. Vomiting: May occur secondary to medication or illness but is not a defining feature.
Correct Answer is C
Explanation
A. Supine: This position can impair lung expansion and increase risk of aspiration or atelectasis.
B. Side-lying: May improve comfort but does not optimize bilateral lung expansion.
C. Upright: An upright or semi-Fowler's position maximizes chest expansion and oxygenation-the most effective for respiratory distress.
D. Prone: Prone may be used in ICU settings for ARDS but is not first-line for general respiratory distress in children.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.