Patient Data

Exhibits

The nurse reviews the client data. Drag the Word Choices to complete the sentence.

Abnormal FHR patterns can result in

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Rationale:

• Weight 35 lbs (15.87 kg): Weight is appropriate for a 24-month-old, indicating adequate growth and nutrition. Growth trends should continue to be monitored but currently show no concern.
• Toddler speaks in 3 to 4 word sentences: Speech is appropriate for developmental age, indicating normal language and cognitive development. Age-appropriate communication supports healthy social and cognitive growth.
• Bottle habit: Bottle provided at nap and bedtime: Prolonged bottle use increases the risk of dental caries and otitis media. Nighttime bottles contribute to poor oral hygiene and may worsen ear infections. Intervention includes education on limiting bottles and transitioning to cups.
• Blood pressure 90/40 mm Hg: Blood pressure falls within expected range for a toddler. No signs of hypotension or cardiovascular compromise are present. Routine monitoring is sufficient.
• Temperature 102.6° F (39.7° C) axillary: Fever indicates an active infection requiring monitoring and possible treatment. High temperatures can increase metabolic demand and dehydration risk. Nurse should assess for signs of worsening illness and educate parents on fever management.
• Diaper count in 24 hour period 6 to 8 with urine: This indicates adequate hydration and normal renal function. Urine output is within expected limits for age and fluid intake. No interventions are required related to hydration status.

Rationale:

A. Document the finding in the infant's record: Documentation is necessary for all assessment findings, but an irregular heart rate in a newborn may indicate a potentially serious cardiac issue. Simply recording it without notifying the healthcare provider could delay critical evaluation or intervention.

B. Teach the parents about congenital heart defects: Parental education is important, but it is not the immediate priority when a newborn has an irregular heart rate. Immediate assessment and guidance from a healthcare provider take precedence over education.

C. Apply oxygen per nasal cannula at 3 L/min: Administering oxygen is only indicated if the infant shows signs of hypoxia or respiratory distress. An irregular heart rate alone does not automatically require supplemental oxygen without further assessment.

D. Notify the pediatrician immediately: Immediate notification of the pediatrician is essential because an irregular heart rate may signal arrhythmias, congenital heart defects, or other serious cardiac conditions. Prompt evaluation ensures timely intervention to prevent complications.