A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?
BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F)
BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F)
BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F)
BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)
The Correct Answer is B
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This statement is incorrect; effective asthma management should help the child attend school regularly rather than miss fewer days.
B. Coughing and shortness of breath in the morning usually indicate poor asthma control, not good control.
C. Eliminating allergens that irritate the lungs is an effective strategy for asthma management and prevention of attacks.
D. Proper asthma management should allow participation in physical activities, not exclude the child from them.
Correct Answer is D
Explanation
A. The conjunctivae can show signs of cyanosis but is not the most reliable indicator of central cyanosis.
B. Ear lobes may show peripheral cyanosis but are not reliable for central cyanosis.
C. The soles of the feet are not typically assessed for cyanosis in this context.
D. The oral mucosa is the most reliable indicator of central cyanosis, as it reflects the oxygenation status of the blood more accurately.
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