A nurse is reviewing the assessment findings of a paediatric patient. Which finding will the nurse prioritize?
Lethargy and hypotonia
Elastic skin turgor
Apical heart rate 64 beats per minute
Blood pressure = 100/54 mmHg
Flat anterior fontanel
The Correct Answer is C
Choice A reason: Lethargy and hypotonia are concerning symptoms that indicate a significant decrease in muscle tone and alertness, which can be associated with various medical conditions. However, they may not require immediate intervention compared to a critically low heart rate.
Choice B reason: Elastic skin turgor is generally a normal finding, indicating good hydration status and skin elasticity. It does not require urgent attention.
Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a paediatric patient, indicating bradycardia. This requires immediate attention and intervention to ensure the patient's cardiovascular stability.
Choice D reason: A blood pressure of 100/54 mmHg is within a normal range for many paediatric patients and does not indicate an immediate emergency.
Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Haemophilia patients often require Factor VIII replacement therapy before procedures such as dental cleanings to prevent bleeding. The statement that the child does not need Factor VIII before a dental cleaning indicates a misunderstanding of the need for prophylactic treatment.
Choice B reason: Aspirin is contraindicated for children with haemophilia as it can inhibit platelet function and increase the risk of bleeding. The statement that it is okay to use aspirin reflects a lack of understanding of the appropriate pain management for haemophilia.
Choice C reason: While it is important for children with haemophilia to stay active, certain high-impact or contact sports may increase the risk of bleeding and should be avoided. The statement that there are no limitations on the type of activities indicates a lack of awareness about the need to choose safe activities.
Choice D reason: Swimming is a low-impact activity that is generally safe and beneficial for children with haemophilia. It promotes cardiovascular fitness and muscle strength without putting undue stress on the joints or increasing the risk of bleeding. This statement demonstrates an understanding of appropriate activity choices for a child with haemophilia.
Correct Answer is C
Explanation
Choice A reason: This statement suggests a rigid schedule for feeding, which may not always align with an infant's natural hunger cues. While some babies may follow a regular feeding pattern, it's essential to prioritize the baby's hunger cues over a strict schedule. Feeding on demand, when the baby shows signs of hunger, is generally recommended to ensure they receive adequate nutrition and comfort.
Choice B reason: Advising not to wake a sleeping baby for feeding is not accurate for all situations. Newborns, especially in the first few weeks, may need to be woken for feeding if they are not gaining weight adequately or if they have medical conditions that require regular feeding. It is important to balance letting the baby sleep and ensuring they get enough nutrition, particularly in the early stages.
Choice C reason: Feeding the baby when they start smacking their lips or sucking on their hands demonstrates an understanding of responding to hunger cues. These behaviours are early signs of hunger, and feeding the baby at this stage can prevent them from becoming overly hungry and fussy. This approach aligns with best practices for feeding on demand, promoting healthy growth and development.
Choice D reason: This statement reflects a misunderstanding of infant care. Crying is a late sign of hunger, and it is important to respond to early hunger cues to prevent distress. The idea that responding too soon to a baby's needs will spoil them is a myth. Timely and responsive care fosters a sense of security and trust in the caregiver-infant relationship, contributing to the baby's overall well-being.
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