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. "I will collect the first drop of blood by wiping it on the test strip." The first drop of blood should be wiped away with a clean cotton ball or gauze. This is because the first drop can contain interstitial fluid that may dilute the sample and lead to an inaccurate reading.
B. "I will stick the side of my finger with the lancet instead of the center." Sticking the side of the fingertip is less painful and allows for better blood flow compared to the center of the fingertip, which is often more sensitive.
C. “I will hold the lancet at a 45-degree angle when piercing my skin.” The lancet should typically be held at a 90-degree angle (straight) when piercing the skin, not at a 45-degree angle. A correct angle ensures proper blood flow and reduces discomfort.
D. “I will place my finger under cool water for a few seconds before the stick.” Using cool water before testing can cause the blood vessels to constrict. Warm water is recommended before testing, as it helps increase blood flow and makes it easier to obtain a sample.
Correct Answer is C
Explanation
A. Hopscotch: Hopscotch typically requires the ability to hop on one foot and follow a structured set of rules, which may be too advanced for a 2-year-old. Toddlers are still developing coordination and motor skills, so activities like hopscotch are not age-appropriate.
B. Beginner sports: While toddlers can start developing coordination, organized sports (even beginner ones) usually require more advanced skills like following directions and teamwork, which may not be suitable for a 2-year-old.
C. Finger paints: Finger painting is an ideal activity for a 2-year-old. It encourages creativity, helps with fine motor skills, and is enjoyable for toddlers as they explore textures and colors. It is a developmentally appropriate form of play.
D. 30-piece puzzle: A 30-piece puzzle may be too complex for a 2-year-old. Toddlers typically enjoy simpler puzzles with larger pieces, which are easier for their developing fine motor skills and cognitive abilities. A simpler puzzle would be more appropriate.
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