A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?

BP 90/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38°C (100.4°F).

BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6°C (99.7°F).

BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7°C (98.1°F).

BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F). . .

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale

A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.

Choice B rationale

While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.

Choice C rationale

The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.

Choice D rationale

The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.

Choice B rationale

Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.

Choice C rationale

Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.

Choice D rationale

Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.

A. The toddler cannot stand upright without support. B. The toddler cannot build a tower of six to seven cubes. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

The inability to stand upright without support at 15 months is a developmental delay that should be reported to the provider. By this age, most toddlers can stand and walk independently. Delays in motor skills can indicate underlying neurological or musculoskeletal issues.

Choice B rationale

Building a tower of six to seven cubes is a skill typically developed by 24 months. At 15 months, a toddler may only be able to stack two to three cubes.

Choice C rationale

Jumping with both feet is a skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to be able to jump with both feet.

Choice D rationale

Turning a doorknob is a fine motor skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to have this skill.

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A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?