A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.
Abdominal girth.
Blood pressure.
Heart rate.
Oxygen saturation.
Correct Answer : B,C,D
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to communicate any concerns to the primary care provider, this response does not provide immediate reassurance or information to the mother about her newborn’s crossed eyes.
Choice B rationale
This is the most therapeutic response. It provides factual information that can reassure the mother. Newborns often lack the muscle control to regulate eye movement, which can result in temporary crossing of the eyes.
Choice C rationale
Taking the baby to the nursery for further examination may cause unnecessary worry for the mother. It’s better to provide reassurance and education first.
Choice D rationale
This response may cause unnecessary worry for the mother. Strabismus, or constant misalignment of the eyes, is not typically seen in newborns and would require treatment. However, temporary crossing of the eyes due to lack of muscle control is normal. Propranolol Propranolol Explore
Correct Answer is A
Explanation
Choice A rationale
The statement “Our car seat is an infant model and is anchored in the car” indicates a correct understanding of car seat safety. Infant car seats are specifically designed to protect infants during a collision. They are rear-facing seats, which is the safest position for an infant because it provides the most support for the infant’s head, neck, and spine. Anchoring the car seat in the car is crucial as it ensures the seat stays in place during a collision.
Choice B rationale
The statement “The car seat is rear-facing in the front passenger seat” is incorrect. It is not safe to place a rear-facing car seat in the front passenger seat of a vehicle. In the event of a collision, an airbag can deploy and hit the car seat, causing serious injury to the infant.
Choice C rationale
The statement “I can fit my hand between the baby and the car seat harness” is incorrect. The harness of a car seat should be snug against the baby’s body. If you can fit your hand between the baby and the harness, it means the harness is too loose, which can be dangerous in the event of a collision.
Choice D rationale
The statement “Our car seat is front-facing in the back seat” is incorrect. Infants should always be in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
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