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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.

Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.

Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.

Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.

A. Suggest that the client wear facility clothing until the prosthesis fitting. B. Encourage the client to visit with someone who has had an amputation. C. Discourage the client from touching the residual limb for the first week. D. Reassure the client that the rehabilitation program is optional.

Correct Answer is B

Explanation

Encourage the client to visit with someone who has had an amputation.

This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.

Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.

Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.

Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 collecting data from a 24-month-old toddler during an annual physical examination. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following a below-the-knee amputation. Which of the following strategies should the nurse include to help the client progress toward acceptance of this body image alteration?

Correct Answer is B

Explanation

A nurse is planning care for a client who is 1 day postoperative following abdominal surgery. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse on an inpatient unit is assisting with the discharge plan for a client who has schizophrenia. Which of the following resources should the nurse include in the plan?

A nurse is using an interpreter to communicate with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

A nurse is caring for a client who is at 10 weeks of gestation and reports nausea and vomiting on most days. Which of the following recommendations should the nurse make?

A nurse is collecting data from a client who is at 29 weeks of gestation. Which of the following findings should the nurse identify as a potential indication of a prenatal complication?

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).