A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate
"The fever is causing an increase in your baby's heart rate."
"Your baby's heart is beating fast in an attempt to cool down his body
“This is within the expected range for your baby."
"As your baby begins to fall asleep, his heart rate will decrease.
The Correct Answer is A
A. In the case of a fever, the body's response often includes an increase in heart rate to help distribute heat and manage the fever.
B. While the body might attempt to regulate temperature through various means, the increased heart rate is primarily due to the fever itself.
C. A heart rate of 190/min is higher than normal for a 2-month-old infant and is likely elevated due to the fever.
D. Heart rate tends to decrease during sleep but doesn't explain the elevated heart rate specifically in response to the fever.
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Related Questions
Correct Answer is A
Explanation
A. Discussing the influence of peers on the child's diet can help identify potential social factors contributing to unhealthy eating habits and enable strategies to counteract them.
B. While involving the parents in the care plan is important, asking who they want to work with might not directly address the child's risk of being overweight.
C. Determining the need for additional caloric intake might not be the primary concern for a child at risk for being overweight; rather, it's about healthy eating habits and portion control.
D. Interviewing the parents about their eating habits could be beneficial for understanding the family's overall approach to nutrition but may not directly address the child's weight risk and potential interventions.
Correct Answer is A
Explanation
A. The step reflex is an expected primitive reflex in infants, disappearing around 2 months of age.Therefore, if ounf in a 4 month old baby, the nurse should be concerned.
B. The plantar grasp reflex should be present in infants and typically disappears by 9 to 12 months of age.
C. Neck righting reflex is a normal response in infants, allowing them to orient their heads in relation to their body movements.
D. The Babinski reflex is typically present in infants but should disappear by around 12 months of age. If it persists beyond this age, it could indicate neurological concerns and warrant further evaluation. therefore, the reflex is normal in a 44 month old baby
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