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Patient Data

Exhibits
The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.

Bulging tympanic membranes

Pain rating of 5 using FLACC scale

Refusal of bottle

Temperature: 101° F (38.3° C)

Agitation while collecting vital signs

Use of pacifier

Heart rate of 188 beats/minute

Respirations: 56 breaths/minute

Warm, pale skin

Answer and Explanation

Correct Answer : A,C,G,H,I

Rationale:

A. Bulging tympanic membranes: Bulging and erythematous tympanic membranes indicate acute otitis media, which requires prompt evaluation and potential antibiotic therapy to prevent complications. Immediate follow-up ensures proper management.

B. Pain rating of 5 using FLACC scale: Moderate pain reflects the infant’s discomfort from the ear infection. Pain management with acetaminophen is appropriate, but it does not require urgent intervention beyond scheduled analgesics.

C. Refusal of bottle: Refusal to feed may indicate dehydration, lethargy, or worsening illness. This symptom warrants immediate assessment to ensure the infant receives adequate hydration and nutrition.

D. Temperature: 101°F (38.3°C): Low-grade fever is common in infections and can be managed with antipyretics. It does not alone require urgent follow-up unless it rises or persists.

E. Agitation while collecting vital signs: Temporary agitation is expected during procedures in infants and is not an indicator of deterioration. Observation is sufficient.

F. Use of pacifier: Pacifier use provides comfort and is non-concerning. It does not indicate a need for immediate follow-up.

G. Heart rate of 188 beats/minute: Tachycardia in a 4-month-old exceeds normal limits and may indicate fever, dehydration, or early sepsis. Prompt follow-up is necessary to identify underlying causes.

H. Respirations: 56 breaths/minute: Tachypnea exceeds the normal range for this age group (30–50 breaths/minute) and may indicate respiratory distress or infection, requiring immediate assessment.

I. Warm, pale skin: Warm, pale skin can signal poor perfusion or early circulatory compromise. Immediate evaluation ensures the infant’s hemodynamic status is stable.

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Correct Answer is D

Explanation

Rationale:

A. Family history of breast cancer: While a family history of breast cancer is important for long-term health risk assessment, it does not directly affect the timing of menarche or cause delayed menstruation in adolescents.

B. Tanner stage 2 of breast development: Tanner stage 2 indicates early pubertal development, which is typical for girls approaching menarche. Although this shows puberty has begun, it is not itself a cause of delayed menstruation.

C. Hemoglobin of 10 g/dL (100 g/L): A hemoglobin level of 10 g/dL represents mild anemia, which may affect overall health but is not usually sufficient alone to delay the onset of menstruation.

D. Low body mass index (BMI): A low BMI can result in insufficient body fat necessary for the hormonal regulation of menstruation. Adolescents with low BMI may experience delayed menarche due to decreased estrogen production and energy availability required for the onset of ovulatory cycles.

A. ABO blood group and Rh status. B. Ultrasound report to confirm gestational age. C. Hemoglobin and hematocrit drawn at 28-weeks. D. Location of placenta on ultrasound report.

Correct Answer is D

Explanation

Rationale:

A. ABO blood group and Rh status: Knowing the client’s blood type and Rh factor is important in preparation for potential transfusion or Rh immunoglobulin administration but it is not the most urgent information to review initially when assessing acute vaginal bleeding.

B. Ultrasound report to confirm gestational age: Confirming gestational age is useful for overall assessment and planning, but it does not provide immediate guidance for managing active, bright red bleeding.

C. Hemoglobin and hematocrit drawn at 28-weeks: Previous hemoglobin and hematocrit values provide a baseline for assessing blood loss, but these values are outdated and do not reflect the client’s current status in the context of acute bleeding.

D. Location of placenta on ultrasound report: The location of the placenta is critical to determine if the client may have placenta previa, which is a leading cause of painless, bright red vaginal bleeding in the third trimester.

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Patient Data Exhibits The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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Patient Data

Exhibits
The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.