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 {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Consult the child life specialist for guidance: A child life specialist can help the parent navigate the difficult conversation with their adolescent, providing strategies for addressing sensitive topics like metastasis and death.
- Reinforce teaching to the parent regarding the adolescent's potential emotional responses: Educating the parent on common emotional responses helps them prepare for and better support their adolescent through this challenging time.
Rationale for Incorrect Choices:
- Encourage the parent to hide their emotions from their adolescent: Hiding emotions can create barriers to trust and communication, which can make the adolescent feel isolated or confused.
- Instruct the parent to withhold the test results from their adolescent: Withholding important information can prevent the adolescent from understanding their condition and making informed decisions about their care.
- Discourage the parent from discussing the possibility of death with their adolescent: Avoiding discussions about death can prevent the adolescent from processing their emotions and understanding the reality of their situation.
- Collaborate with the RN to initiate a referral for admission to hospice care: Hospice care should only be considered after emotional support and clear communication have been established, not prematurely without addressing emotional needs first.
Correct Answer is C
Explanation
A. Absence of Babinski reflex: The Babinski reflex (a fanning of the toes when the sole of the foot is stroked) is normal in infants and should be present until around 12 months of age. Its absence at 6 weeks would be atypical.
B. Absence of Moro reflex: The Moro reflex (a startle response) is typically present in newborns and may begin to disappear by 3-6 months of age. Its absence at 6 weeks would be concerning and could indicate neurological issues.
C. Closure of the posterior fontanel: The posterior fontanel typically closes by 6-8 weeks of age. This is a normal finding for a 6-week-old infant.
D. Closure of the anterior fontanel: The anterior fontanel typically closes between 12 and 18 months of age, not by 6 weeks. Therefore, closure of the anterior fontanel at 6 weeks would be unusual.
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