The nurse is assessing the vital signs of a 3-week-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, what is the most appropriate action?

Administer Oxygen

Document the findings

Reassess the respiratory rate in 15 minutes

Notify the health care provider

Answer and Explanation

The Correct Answer is B

A. Administering oxygen is unnecessary, as the respiratory rate is within the normal range for a 3-week-old (30-60 breaths/min).

B. A respiratory rate of 35 breaths/minute is normal for an infant, so the nurse should document this finding.

C. Reassessing the respiratory rate is unnecessary unless other symptoms are present.

D. There is no need to notify the healthcare provider, as the respiratory rate is within normal limits.

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Correct Answer is A

Explanation

A. Children who ingest non-food substances, such as dirt (pica), are at an increased risk for lead exposure, especially if they live in environments where lead contamination is present in soil.

B. Parents working in certain industries can bring home lead dust on their clothes, but this is less likely in the textile industry compared to occupations like construction or manufacturing.

C. Growth percentile does not directly increase the risk for lead poisoning.

D. A recent diagnosis of autism spectrum disorder is not directly associated with an increased risk of lead exposure.

A. Allow the child to wait until later that afternoon after a trip to the playroom to receive the injection. B. Provide comfort measures after the procedure, such as touching, holding, or providing a favorite toy. C. Accept aggressive behavior, within reasonable limits, as a normal response, and provide healthy outlets for the child. D. Offer a brief, concrete explanation of the procedure and then perform it.

Correct Answer is ["B","C","D"]

Explanation

A. Delaying the injection may increase the child's anxiety and fear regarding the procedure; it is better to proceed without unnecessary delays.

B. Providing comfort measures after the injection helps to ease the child's distress and provides reassurance during recovery.

C. Accepting and acknowledging the child’s aggressive behavior as a normal reaction to fear helps the child process their feelings, while offering healthy outlets helps manage these feelings.

D. Offering a brief, concrete explanation helps prepare the child for what to expect, reducing anxiety and making the procedure more manageable.

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The nurse is assessing the vital signs of a 3-week-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, what is the most appropriate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for children. Which of the following children are at risk for developing lead poisoning?

Correct Answer is A

Explanation

The nurse is preparing to give an injection to a 3-year-old child. Which of the actions by the nurse is appropriate? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

A nurse is preparing to assess a preschool age child. Which of the following is an appropriate action by the nurse to prepare the child for the assessment?

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