A nurse is obtaining vital signs from the 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."
"This is within the expected range for your baby."
"Your baby's heart is beating fast in an attempt to cool down his body."
"As your baby begins to fall asleep, his heart rate will decrease."
The Correct Answer is A
A. "The fever is causing an increase in your baby's heart rate." Fever increases metabolic demand, which commonly leads to tachycardia in infants as the body attempts to regulate temperature and support circulation. This explanation directly addresses the physiological cause and is appropriate.
B. "This is within the expected range for your baby." A heart rate of 190/min in a 2-month-old is elevated, especially in the presence of a fever. While infants have higher baseline heart rates (120-160 b/min), this value is elevated and requires clinical interpretation, not reassurance.
C. "Your baby's heart is beating fast in an attempt to cool down his body.": While increased cardiac output may help distribute heat, the primary cause of tachycardia is metabolic demand from fever—not a direct mechanism to cool the body.
D. "As your baby begins to fall asleep, his heart rate will decrease." Although heart rate may decrease with sleep, this does not address the father's concern about the elevated rate now, and it downplays the need to monitor the infant in the context of high fever
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Preoperational: During the preoperational stage (ages 2 to 7), children develop symbolic thinking and engage in imaginative play, but object permanence has already been established before this stage begins.
B. Concrete operational: This stage (ages 7 to 11) involves logical thinking about concrete events and understanding concepts like conservation, but object permanence develops much earlier in infancy.
C. Formal operational: The formal operational stage (ages 11 and up) is marked by abstract reasoning and hypothetical thinking. Object permanence is fully developed long before this stage.
D. Sensorimotor: Object permanence begins to emerge during the sensorimotor stage (birth to 2 years), as infants learn that objects continue to exist even when they are not visible—typically around 8 to 12 months of age.
Correct Answer is D
Explanation
A. "Newborns do not expand their lungs fully with each respiration." While newborns have smaller lung capacity and immature respiratory mechanics, this does not directly explain why the respiratory rate must be counted for a full minute.
B. "Newborns are abdominal breathers." Abdominal breathing is common in newborns due to diaphragmatic dominance, but this characteristic does not necessitate counting respiratory rate for a full minute. It affects observation location more than timing.
C. "Activity will increase the respiratory rate." Activity level can cause fluctuations in respiratory rate, but the need to count for a full minute is primarily related to irregular rhythm, not just activity changes. Activity effects are an additional consideration but not the main reason.
D. "The rate and rhythm of breath are irregular in newborns." Newborns commonly have irregular breathing patterns, including variable rate and pauses (periodic breathing), which requires a full minute count to accurately assess their true respiratory rate and avoid misinterpretation.
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