A nurse is taking vital signs on an infant diagnosed with bronchiolitis. Which of the following findings should the nurse immediately report to the provider?
Heart rate of 152 beats per minute
Temperature of 99.5°F (37.5°C)
Respiratory rate of 74 breaths per
Blood pressure of 90/60 mmHg
The Correct Answer is C
A. An elevated heart rate can be expected in infants with bronchiolitis due to increased work of breathing.
B. A slight elevation in temperature may be indicative of infection but is not an immediate concern.
C. A respiratory rate of 74 breaths per minute may indicate respiratory distress and warrants immediate attention.
D. A blood pressure of 90/60 mmHg is within the normal range for infants and not immediately concerning.
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Related Questions
Correct Answer is D
Explanation
A. Assessing parental anxiety is important but not the priority immediately after admission.
B. Pain assessment is important but not the priority assessment in acute rheumatic fever.
C. Assessing the erythematous rash is relevant but not the priority compared to cardiac assessment.
D. Auscultating the rate and characteristics of the child's heart sounds is crucial for early detection of cardiac involvement, which is a priority in acute rheumatic fever.
Correct Answer is B
Explanation
A. A barking cough is a symptom of acute laryngotracheobronchitis and does not indicate treatment effectiveness.
B. Decreased stridor suggests improved airway patency, indicating the effectiveness of the cool mist tent therapy.
C. Improved hydration is important but is not a direct indicator of the effectiveness of the cool mist tent.
D. Decreased temperature may indicate resolution of fever but does not directly reflect the effectiveness of the cool mist tent therapy
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