A newborn was admitted to the hospital with vomiting and dehydration. The newborn's heart rate is 170, respiratory rate is 44, blood p 85/52, and temperature is 99 Degree F (37.2 Degree C). What is the nurse's best response to the parents who ask if the vital signs are normal?
"The blood pressure is elevated, but the other vital signs are within normal limits”
"The heart rate is elevated, but the other vital signs are within normal limits"
"The temperature is elevated, but the other vital signs are within normal limits"
“The respiratory rate is elevated, but the other vital signs are within normal limits"
The Correct Answer is B
While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn.
It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.
B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.
C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.
D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.
Correct Answer is D
Explanation
The hepatitis B vaccine is typically administered to newborns shortly after birth, usually within 24 hours.
The measles, mumps, rubella (MMR) vaccine is typically given between 12 and 15 months of age, not at 6 months.
The first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not at the 2-week visit.
The pneumococcal conjugate vaccine (PCV) is typically given in a series, starting at 2 months of age, and is completed by the age of 12-15 months. It is not given specifically on the first birthday.
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