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 C

Explanation

A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.

Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.

Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.

Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.

A. Homocysteine. B. Indirect Coombs. C. Erythropoietin. D. aPTT.

Correct Answer is B

Explanation

The indirect Coombs test is used to detect antibodies against foreign red blood cells in the maternal serum. This test can help identify maternal-fetal blood incompatibility, which can cause hemolytic disease of the newborn.

Choice A is wrong because homocysteine is a type of amino acid and is not related to blood compatibility.

Choice C is incorrect because erythropoietin is a hormone that regulates red blood cell production and is not a specific test for detecting maternal-fetal blood incompatibility.

Choice D is not the correct answer as aPTT (activated partial thromboplastin time) is a test used to evaluate blood clotting factors and is not directly related to monitoring maternal-fetal blood incompatibility.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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