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 D
Explanation
The nurse should plan to administer the human papillomavirus (HPV) vaccine to the 12-year-old client.
The Centers for Disease Control and Prevention (CDC) recommends that children aged 11-12 years old receive two doses of the HPV vaccine separated by 6-12 months.
Choice A is wrong because Hepatitis A vaccine is typically given to children at age.
Choice B is wrong because Varicella vaccine is typically given to children at ages 12-15 months and 4-6 years.
Choice C is wrong because DTaP vaccine is typically given to children at ages 2, 4, and 6 months, and between ages 15-18 months and 4-6 years.
Correct Answer is D
Explanation
The accessory nerve is tested by evaluating the function of the trapezius and sternocleidomastoid muscles.
The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance.
Choice A is wrong because following a light in the six cardinal positions tests the function of cranial nerves III, IV, and VI.
Choice B is wrong because moving their tongue in all directions tests the function of cranial nerve XII.
Choice C is wrong because showing their teeth while smiling tests the function of cranial nerve VII.
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