A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate

"The fever is causing an increase in your baby's heart rate."

"Your baby's heart is beating fast in an attempt to cool down his body

“This is within the expected range for your baby."

"As your baby begins to fall asleep, his heart rate will decrease.

Answer and Explanation

The Correct Answer is A

A.   In the case of a fever, the body's response often includes an increase in heart rate to help distribute heat and manage the fever.
B.   While the body might attempt to regulate temperature through various means, the increased heart rate is primarily due to the fever itself.
C.   A heart rate of 190/min is higher than normal for a 2-month-old infant and is likely elevated due to the fever.
D.   Heart rate tends to decrease during sleep but doesn't explain the elevated heart rate specifically in response to the fever.

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Correct Answer is D

Explanation

A. Stating that being gay puts someone in an "at-risk" category can be stigmatizing and might not address the teenager's concerns or questions.
B. While discussing safe sex might be important, it assumes that being gay automatically implies a need for this conversation, which might not be the case.
C. Dismissing the teenager's statement by denying his sexual orientation can be harmful, dismissive, and invalidate the individual's feelings and identity.
D. Encouraging open communication and asking the teenager to share his thoughts fosters a supportive environment, allowing the nurse to understand the teenager's perspective and concerns.

A. Advising about increased caloric needs B. Explaining how to prepare table foods C. Discussing the type of sippy cup to use D. Describing the tongue extrusion reflex

Correct Answer is C

Explanation

A. Advising about increased caloric needs might not be the primary focus unless specific growth concerns are present.
B. At 7 months, while introducing table foods might be on the horizon, it's not the most immediate concern during this well-child visit.
C. Discussing the type of sippy cup to use is pertinent as the infant is approaching an age where the introduction of a sippy cup becomes relevant for transitioning from a bottle.
D. Describing the tongue extrusion reflex might be more relevant for younger infants just starting on solids, typically around 4 to 6 months, rather than at 7 months.

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A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate

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Naxlex Comprehensive Predictor Exams

During a health check-up without his parents, a 17-year-old tells the nurse he is gay. Which approach should the nurse take?

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