A nurse is caring for a 2-month-old infant. Which of the following findings should the nurse report to the provider?
Blood pressure 95/58 mm Hg
Respiratory rate 18/min
Temperature 37.4° C (99.3°F)
Heart rate 160/min
The Correct Answer is B
A. A blood pressure of 95/58 mm Hg can be within an acceptable range for an infant and is not typically a cause for concern in a 2-month-old.
B. A respiratory rate of 18/min is abnormally low for a 2-month-old infant. Infants normally have a respiratory rate of about 30–60/min, and a low rate may indicate respiratory depression or other serious issues that should be reported promptly.
C. A temperature of 37.4° C (99.3°F) is within the expected range for an infant and does not indicate fever.
D. A heart rate of 160/min is within the normal range for a young infant, especially when awake or active.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You should chill your medication before administration." Insulin should not be chilled before administration. It should be stored in a cool place, but administering insulin directly from the refrigerator can cause discomfort.
B. "You should rotate sites when administering the medication." Rotating injection sites helps prevent tissue damage and the formation of lumps or scar tissue. It is recommended to rotate sites within the same area (e.g., abdomen, thigh, etc.) to ensure absorption and prevent complications.
C. "You should administer your medication at a 45-degree angle." Insulin should generally be administered at a 90-degree angle for subcutaneous injection, not a 45-degree angle. A 45-degree angle may be appropriate.
D. "You should administer your insulin into a muscle." Insulin should be administered subcutaneously (into the fat layer just under the skin), not into the muscle. Injecting insulin into a muscle can alter its absorption rate and may cause irritation or pain.
Correct Answer is C
Explanation
A. “I can leave my child alone in the bathtub for up to 15 minutes after they learn to swim." Leaving a toddler alone in the bathtub is not safe, even if they know how to swim. Drowning occurs very quickly, and toddlers should always be supervised when in or near water.
B. "Open windows are safe as long as the screens fit snugly." Even if the screens fit snugly, open windows still pose a risk of falls for toddlers. It is important to keep windows securely closed or use window guards to prevent accidents.
C. "The water heater should be set to 120 degrees Fahrenheit or less." Setting the water heater to 120°F or lower is an appropriate and safe recommendation to prevent burns. Water temperatures higher than 120°F can cause serious burns, especially in young children.
D. “I will tell my toddler to never touch a firearm." Simply telling a toddler to avoid firearms may not be enough. Firearms should be securely stored in a locked, childproof safe, away from the child's reach, regardless of what the child is told.
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