A nurse is assessing a 6-month-old baby with volvulus. The infant's vital signs are as follows: pulse: 118 beats/minute; blood pressure: 78/54 mm Hg; respirations: 42 breaths/minute. What action by the nurse is most appropriate?
A.
Assess the infant's abdomen and skin.
B.
Document the findings in the baby's chart.
C.
Increase the rate of IV fluid administration.
D.
Notify the health-care provider immediately.
ANS: B
These vital signs are appropriate for a 6-month-old baby. The nurse should document the findings in the patient's chart. A full assessment is completed, but specific assessments are not needed based on these vital signs. The IV rate does not need adjustment, and there is no need to inform the provider.
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