During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?
Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.
Measure the child's blood pressure three times during the visit and determine the highest of the readings.
Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.
Take the blood pressure two more times during the visit and determine the average of the three readings.
The Correct Answer is D
If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks
A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings
B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination
C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Many infants with congenital heart defects exhibit audible murmurs due to turbulent blood flow through abnormal openings or stenotic valves. While a murmur is a diagnostic hallmark of the condition, it is often an expected finding and does not necessarily indicate acute physiological deterioration. The nurse must document the murmur, but it is rarely the most urgent finding to report.
B. A heart rate of 162 beats/minute in an infant is slightly elevated above the typical resting range but can be triggered by crying, feeding, or baseline cardiac stress from the defect. Although tachycardia requires close monitoring to ensure the infant is not entering a state of high-output failure, it is less critical than signs of fluid overload. It represents a compensatory mechanism rather than an immediate life-threatening complication.
C. Infants with cardiac defects often experience fatigue during feeding because of the high metabolic demand and decreased cardiac output. Poor suckling effort and inadequate oral intake are common symptoms of pediatric heart failure that lead to failure to thrive over time. While this finding is significant for long-term nutritional management, it does not suggest an acute, rapid shift in stability like sudden weight changes.
D. Rapid weight gain of 1 kg within 48 hours is the most critical finding because it indicates acute fluid volume excess and potential congestive heart failure. In an infant, such a significant increase is almost certainly due to fluid retention rather than nutritional growth. This clinical sign suggests that the heart is unable to manage the systemic or pulmonary circulation effectively, necessitating immediate medical intervention.
Correct Answer is ["1"]
Explanation
1 teaspoon.
The child has been prescribed loratadine 5 mg once a day. The botle is labeled "Loratadine for Oral Suspension, USP 5 mg per 5 mL." This means that for every 5 mL of the suspension, there is 5 mg of loratadine. Since 1 teaspoon is equivalent to 5 mL, the nurse should instruct the parent to administer 1 teaspoon with each dose to provide the prescribed 5 mg of loratadine.
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