A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

Respiratory rate 68/min.

BP 64/42 mm Hg.

Axillary temperature 36.6° C (97.9° F).

Apical heart rate 124/min.

Answer and Explanation

The Correct Answer is A

This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.

Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.

Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).

Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.

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Correct Answer is D

Explanation

The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.

Choice A is wrong because wheat is not a latex cross-reactive food.

Choice B is wrong because strawberries are a low or undetermined cross- reactive food.

Choice C is wrong because peanuts are a low or undetermined cross-reactive food.

Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.

A. Report of pain as 6 on a scale of 0 to 10. B. Pulses 2+ distal to the client’s fracture. C. Petechiae over the client’s chest. D. Bruising around the fracture site.

Correct Answer is C

Explanation

This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.

Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.

Pain is a common symptom of many conditions and injuries.

Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.

Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.

Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.

Petechiae are small red or purple spots on the skin caused by bleeding under the skin.

They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.

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A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a newly diagnosed latex allergy. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer is D

Explanation

A nurse is caring for a client who has a compound fracture of the femur. Which of the following findings should the nurse report to the provider as a manifestation of a fat embolism?

Correct Answer is C

Explanation

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