The nurse is assessing a 1-year-old infant in the pediatric office.
What finding should the nurse report to the physician immediately?
Fussy behavior.
Minimal verbalization.
Pulse rate of 100 beats/minute.
Respiratory rate of 60 breaths/minute.
The Correct Answer is D
Choice A rationale:
Fussy behavior in a 1-year-old infant can be a normal response to discomfort, hunger, or unfamiliar surroundings. It is not typically an immediate concern and does not warrant reporting to the physician immediately.
Choice B rationale:
Minimal verbalization is also common in a 1-year-old infant as they are still in the early stages of language development. It is not typically a finding that requires immediate reporting to the physician.
Choice C rationale:
A pulse rate of 100 beats/minute in a 1-year-old infant can be within the normal range. The normal pulse rate for infants can vary, but it generally falls between 100-160 beats/minute. While it may warrant further observation, it is not an immediate concern that requires reporting to the physician.
Choice D rationale:
A respiratory rate of 60 breaths/minute in a 1-year-old infant is significantly lower than the normal range. The normal respiratory rate for infants is typically between 20-40 breaths per minute. A respiratory rate of 60 may indicate respiratory distress or other underlying issues, which should be reported to the physician immediately for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Speaking in 2-word sentences is not a developmental milestone expected in a 9-month-old infant. Language development typically involves babbling, imitating sounds, and understanding simple commands at this age.
Choice B rationale:
Beginning to use a spoon rather sloppily is also not a typical milestone for a 9-month-old. Infants at this age are just starting to explore solid foods and are more likely to use their hands for self-feeding.
Choice C rationale:
Creeping along the floor is an appropriate developmental milestone for a 9-month-old. This crawling or creeping motion is a precursor to crawling and walking. It's a sign of motor development and exploration.
Choice D rationale:
Grasping objects with a palmar grasp is a skill that infants typically develop at a much younger age, usually within the first few months of life. By 9 months, they should have progressed to a more refined pincer grasp.
Correct Answer is A
Explanation
Choice A rationale:
Push-pull toys are suitable for a 3-year-old because they promote physical activity and coordination. These toys help children develop their motor skills and provide a fun way for them to engage with their environment. Push-pull toys are age-appropriate and safe for toddlers.
Choice B rationale:
A large construction set may have small parts that could be a choking hazard for a 3-year-old. It's essential to select toys that do not pose such risks and are developmentally appropriate. Therefore, this choice is not the most appropriate toy for a 3-year-old.
Choice C rationale:
A small pet, such as a goldfish, is not an appropriate toy for a 3-year-old. Pets are living creatures that require care and attention. Introducing a pet to a young child should be a well-considered decision made by the family and not seen as a toy choice.
Choice D rationale:
A board game is typically too complex for a 3-year-old to fully enjoy and understand. Board games often require following rules, taking turns, and using fine motor skills that may not be well-developed in a child of this age. Therefore, it is not the most appropriate choice.
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