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 A

Explanation

Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.

Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.

Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.

Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.

A. Speak in a louder than usual tone of voice during conversation. B. Mute the client’s television before beginning a conversation. C. Avoid the use of hand gestures when talking to the client. D. Use short phrases when talking to the client.

Correct Answer is D

Explanation

Use short phrases when talking to the client.

Some possible explanations for the other choices are:

Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.

The nurse should speak in a normal tone and enunciate clearly.

Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.

The nurse should use appropriate facial expressions

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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

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