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 {"dropdown-group-1":"F","dropdown-group-2":"E"}
Explanation
Target 1: Digitalis toxicity
The child has been administered digoxin, a cardiac glycoside, multiple times. Digitalis toxicity is a risk due to the narrow therapeutic window of digoxin and the potential for adverse effects, especially if there are signs of worsening heart failure or electrolyte imbalances.
Target 2: Hypokalemia
The administration of furosemide, a loop diuretic, increases the risk of hypokalemia (low potassium levels). Hypokalemia can occur as a result of diuretic therapy and can exacerbate the risk of digitalis toxicity, as digoxin toxicity is often linked to low potassium levels.
Correct Answer is A
Explanation
A. Toddlers are beginning to cooperate in simple chores and tasks, which aligns with their developmental stage.
B. Toddlers often struggle with separation anxiety and do not separate easily from their caregivers.
C. Understanding the difference between right and wrong is a skill that develops later, typically around age 4 or older.
D. Printing letters and numbers is beyond the developmental capabilities of a toddler and is expected later in early childhood.
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