A nurse is reinforcing teaching about nutritional needs of preschoolers with a group of parents. Which of the following foods should the nurse recommend as a source of complete protein?

A. Blood pressure 95/58 mm Hg: A blood pressure of 95/58 mm Hg is within a normal range for a 2-month-old infant. The typical blood pressure for infants in this age group can range from 65/45 mm Hg to 105/70 mm Hg, depending on their overall health.
B. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is low for a 2-month-old. The normal range for infants at this age is between 30 to 60 breaths per minute, so a rate of 18 is too slow and may indicate respiratory distress that should be assessed further.
C. Temperature 37.4° C (99.3°F): A temperature of 37.4°C (99.3°F) is within the normal range for a 2-month-old infant. Normal body temperature for infants typically ranges between 36.5°C to 37.5°C (97.7°F to 99.5°F).
D. Heart rate 160/min: The normal resting heart rate for a 2-month-old infant typically ranges from 100-180 beats per minute (bpm) when awake. A heart rate of 160/min is within this expected range for an infant and does not indicate an abnormality that needs to be reported to the provider.

Rationale for Correct Choices:

• Dextrose 5% in sodium chloride with 20 mEq potassium chloride/L at 75 mL/hr: The prescription for dextrose 5% with potassium chloride at 20 mEq/L should be clarified because the child's potassium level is elevated at 6.2 mEq/L (normal range is 3.4 to 4.7 mEq/L). Administering additional potassium could worsen hyperkalemia, which could lead to dangerous complications like arrhythmias.
• Laboratory values: The child's potassium level is already high, and adding more potassium via IV fluids could increase the risk of severe hyperkalemia. The nurse should clarify this prescription to avoid potential harm.

Rationale for Incorrect Choices:

• Piperacillin and tazobactam 4g IV every 8 hr: This antibiotic is appropriate for treating pneumonia in a child with cystic fibrosis. No issues with laboratory values or contraindications are present in this case, so clarification is unnecessary.
• Dornase alfa 2.5 mg inhalation every day: Dornase alfa is used to break down mucus in the lungs of children with cystic fibrosis, and it is prescribed appropriately for this patient. The child’s current condition and medications do not warrant clarification for this prescription.
• Pancrelipase 8,000 units with meals: Pancrelipase is indicated for the child’s cystic fibrosis to assist with digestion, and the prescribed dosage seems appropriate for the child’s weight and condition.
• Albuterol nebulizer 2.5 mg inhalation every 4 hr: Albuterol is used for airway clearance, which is appropriate for managing the child's respiratory symptoms. No clarification is needed for this prescription based on the current findings.
• Vital signs: While the child's heart rate and temperature are elevated, they are within expected ranges for the child’s condition (fever, pneumonia, and cystic fibrosis). There is no immediate need for clarification of medications based on vital signs alone.
• Scheduled therapapy: The child is scheduled for chest physiotherapy and airway clearance therapy, which are standard treatments for cystic fibrosis and pneumonia. There is no issue with the scheduled therapies that requires clarification of the medications.
• Diet: The child has been prescribed a high-protein, high-fat diet to support nutritional needs, especially important in cystic fibrosis. The diet does not require any clarification in relation to the prescribed medications.
• Pre-existing conditions: The child’s pre-existing condition of cystic fibrosis is already taken into account in the prescribed treatments, and no adjustment is needed based on the conditions present.