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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?

A.

BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F)

B.

BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F)

C.

BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F)

D.

BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

A. Notifying the healthcare provider immediately is the best intervention because spitting up blood post-tonsillectomy could indicate bleeding, which requires prompt medical evaluation and intervention.

B. While continuing to assess for bleeding is important, immediate notification of the healthcare provider takes precedence to address potential complications.

C. Suctioning the throat might be contraindicated and could increase the risk of further bleeding.

D. Encouraging coughing is not appropriate as it could increase bleeding risk.

Correct Answer is A

Explanation

A. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who cannot verbally communicate their pain, making it suitable for a 2-month-old.

B. The FACES scale is used for older children who can point to or choose faces that represent their pain level and is not suitable for a 2-month-old.

C. The OUCHER scale is used for children aged 3 to 13 years and includes pictures representing pain, so it is not appropriate for a 2-month-old.

D. The PANAD scale is not a standard pain rating scale used for infants and is less commonly used than the FLACC scale.

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