A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?
An adolescent who has a BP of 132/82 mm Hg
A 3-month-old infant who has a respiratory rate of 30/min
An 18-month-old toddler who has a heart rate of 68/min
A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
The Correct Answer is C
A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.
B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).
C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.
B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.
C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.
D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.
Correct Answer is D
Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
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