The nurse is performing an assessment on a child and notes the presence of Koplik’s spots. In which communicable disease are Koplik’s spots present?

The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.

Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.

Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.

Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.

Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.

Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.

Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.

Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.

Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.

They may indicate other conditions such as appendicitis or bowel obstruction.

Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.

They may be seen in other causes of vomiting or abdominal distension.

Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.

They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.