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). . .
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Encouraging regular activity level as soon as possible is not appropriate for a child with streptococcal pharyngitis. Rest is important to allow the body to recover and prevent complications.
Choice B rationale
Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever, which can result from untreated or partially treated streptococcal infections.
Choice C rationale
Expecting the lymph nodes to swell and obstruct the airway is not a typical outcome of streptococcal pharyngitis. While lymph node swelling can occur, it usually does not obstruct the airway.
Choice D rationale
Being aware that the infection may spread and cause a tooth abscess is not a common complication of streptococcal pharyngitis. The primary concern is preventing complications like rheumatic fever and ensuring complete recovery. .
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants. It is located at the point of maximal impulse (PMI) and provides the most accurate measurement of the heart rate in this age group.
Choice B rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it can be used for blood pressure measurement, it is not as accurate as the apical pulse for heart rate assessment.
Choice C rationale
The radial artery is not typically used for assessing the heart rate in infants. It is more commonly used in older children and adults.
Choice D rationale
The carotid artery is not recommended for assessing the heart rate in infants due to the risk of compressing the airway and causing discomfort.
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