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
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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Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
A. Doing everything for the child can hinder their ability to develop independence and confidence.
B. Encouraging a toddler to try things for themselves fosters independence and supports their developmental task of gaining autonomy, which is essential at this stage.
C. While teaching right from wrong is important, an overly strict approach may lead to feelings of guilt and inhibit exploration.
D. Providing opportunities for social play is beneficial, but it is not as directly related to the independence that the child needs at this age.
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