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)

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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Correct Answer is D

Explanation

A. Seizures are not a typical complication of polycythemia, though they may occur if the condition progresses to severe levels of blood viscosity.

B. Yellowing of the skin (jaundice) is not associated with polycythemia but with liver conditions.

C. While activity is important, preventing dehydration is more critical in managing polycythemia because dehydration increases blood viscosity, exacerbating the condition.

D. Preventing dehydration is essential as it helps maintain adequate blood flow and reduces the risk of thrombotic events in a child with polycythemia.

A. Dilated scalp veins B. Over-riding suture lines C. A backward sloping appearance of the forehead. D. Hypertension

Correct Answer is A

Explanation

A. This is a common manifestation of hydrocephalus in newborns. The increased cerebrospinal fluid (CSF) in the ventricles causes the skull to expand, which can lead to prominent and dilated scalp veins due to increased intracranial pressure.

B. Over-riding suture lines are more commonly associated with conditions like craniosynostosis or during the early stages of labor when the skull bones overlap. In hydrocephalus, the sutures are more likely to be separated rather than overridden due to the expansion of the skull.

C. This is not a typical manifestation of hydrocephalus. Instead, you would expect a more pronounced or bulging forehead due to increased intracranial pressure.

D. Hypertension is not typically a manifestation of hydrocephalus in newborns. Instead, the condition is more associated with signs of increased intracranial pressure and changes in head size.

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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?

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Naxlex Comprehensive Predictor Exams

Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder?

Correct Answer is D

Explanation

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Correct Answer is A

Explanation

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