A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?
BP 90/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38°C (100.4°F).
BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6°C (99.7°F).
BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7°C (98.1°F).
BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F). . .
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.
Choice B rationale
While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.
Choice C rationale
The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.
Choice D rationale
The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
A sputum culture can help identify respiratory infections but is not definitive for diagnosing cystic fibrosis.
Choice B rationale
Stool fat content analysis can indicate malabsorption issues but is not specific to cystic fibrosis.
Choice C rationale
Pulmonary function tests assess lung function but do not confirm a diagnosis of cystic fibrosis.
Choice D rationale
The sweat chloride test is the gold standard for diagnosing cystic fibrosis. It measures the concentration of chloride in sweat, which is elevated in individuals with cystic fibrosis due to defective chloride transport in sweat glands. .
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.
Choice B rationale
Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.
Choice C rationale
Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.
Choice D rationale
Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.
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