A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 48, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse's best response is:
"Your son's respiratory rate is elevated, but the other vital signs are within the normal range."
"Your son's heart rate is elevated, but the other vital signs are within the normal range."
"Your son's blood pressure is elevated, but the other vital signs are within the normal range."
"Your son's temperature is elevated, but the other vital signs are within the normal range."
The Correct Answer is A
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Clubbed fingers are a sign of chronic hypoxia and may be seen in older children with cystic fibrosis, but they are not typically present at birth.
Choice B reason: This is the correct choice. Meconium ileus is a blockage of the intestines that occurs shortly after birth and is often the first sign of cystic fibrosis.
Choice C reason: A barrel chest is associated with chronic respiratory conditions and would not be present in a newborn.
Choice D reason: Steatorrheic stools, or fatty stools, may occur in cystic fibrosis but are not a primary indicator in a newborn.
Correct Answer is C
Explanation
Choice A reason: Placing the infant flat and prone is not the first priority in the care of an infant with gastroschisis.
Choice B reason: While providing warmth and promoting bonding are important, they are not the immediate priority upon admission for an infant with gastroschisis.
Choice C reason: This is the correct choice. The exposed abdominal organs in gastroschisis must be protected immediately to prevent heat and fluid loss and to reduce the risk of infection.
Choice D reason: Breastfeeding is important for bonding and nutrition but is not the first intervention for an infant with gastroschisis.
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