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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F","G"]
Explanation
A. Development typically progresses from the head (top) to the feet (bottom), reflecting a cephalocaudal pattern.
B. This statement is inaccurate; development is not characterized by functional to nonfunctional but rather by increasing complexity.
C. This pattern is incorrect; development does not proceed from outside to inside but instead follows a different trajectory.
D. The development pattern from the center (proximal) to the periphery (distal) is known as the proximodistal pattern of development.
E. This statement is not correct; development does not follow a bottom-to-top pattern.
F. Development does move from simple skills to more complex skills as infants grow.
G. Growth and development indeed follow a pathway from general skills to more specific tasks as children refine their abilities.
Correct Answer is B
Explanation
A. A soft, squishy ball is safe for infants and can help with tactile exploration and motor skills.
B. A soft, button-eyed stuffed animal may pose a choking hazard if buttons become detached, thus requiring additional guidance on safe toy choices.
C. Colorful rattles are excellent for stimulating an infant’s senses and encouraging grasping and shaking.
D. Cloth books are appropriate for infants, promoting sensory exploration through touch and visual engagement.
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