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?

The correct answer is Choice A.

Choice A rationale

Auscultating the rate and characteristics of the child’s heart sounds is the priority assessment. Acute rheumatic fever can lead to carditis, which affects the heart valves and can cause new or changed heart murmurs.

Choice B rationale

Assessing the client’s erythematous rash is important but not the priority. The rash is a common symptom but does not indicate the severity of the condition.

Choice C rationale

Identifying the degree of parental anxiety is important for providing holistic care but is not the immediate priority in assessing the child’s physical condition.

Choice D rationale

Using a pain-rating tool to determine the severity of joint pain is important for managing symptoms but is not the priority assessment upon admission.

The correct answer is Choice A.

Choice A rationale

Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and ready for administration. This step is crucial for delivering the correct dose of medication.

Choice B rationale

Pressing down twice on the MDI canister is incorrect as it can lead to an overdose of medication. The correct technique involves pressing down once per inhalation.

Choice C rationale

Waiting 2 minutes between inhalations is not necessary. The recommended wait time between inhalations is usually 30 seconds to 1 minute.

Choice D rationale

Rinsing the mouth with mouthwash after inhaling the medication is not recommended. Instead, rinsing with water is advised to prevent oral thrush, especially when using corticosteroid inhalers.