A nurse in a provider's office is assessing the vital signs of a 2-year-old child at a well-child visit.
Which of the following findings should the nurse report to the provider?
Blood pressure 118/74 mm Hg.
Respiratory rate 26/min.
Pulse rate 98/min.
Temperature 37.2° C (99° F).
The Correct Answer is A
According to the normal pediatric vital signs chart provided by Cleveland Clinic, the normal blood pressure range for a 2-year-old child should be between 90- 105/55-70 mm Hg. The blood pressure of 118/74 mm Hg is higher than the normal range for a 2- year-old child and should be reported to the provider.
Choice B is wrong because a respiratory rate of 26/min falls within the normal range of 20-30 breaths per minute for a child between ages 1 and.
Choice C is wrong because a pulse rate of 98/min falls within the normal range of 80-125 beats per minute for a child between ages 1 and.
Choice D is wrong because a temperature of 37.2° C (99° F) falls within the normal range for children which is around 98.6 degrees.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should first check the pH of the gastric secretions to confirm the placement of the NG tube before administering the enteral feeding.
Choice A is wrong because flushing the tube with water should be done after confirming the placement of the NG tube.
Choice B is wrong because attaching the feeding bag tubing to the end of the NG tube should be done after confirming the placement of the NG tube.
Choice D is wrong because setting the administration rate on the feeding pump should be done after confirming the placement of the NG tube.
Correct Answer is ["A","B","D"]
Explanation
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
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