The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:
a. Normal for this age.
b. Lower than expected.
c. Higher than expected, probably as a result of crying.
d. Higher than expected, reflecting persistent tachycardia.
ANS: A
The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.
You might also like to view...
Before LPNs can delegate a function to the CNA, they must:
1. assess the patient carefully. 2. evaluate the patient carefully. 3. plan the care for the patient. 4. write out instructions for the CNA.
The nurse is caring for a child who is prescribed supplemental iron therapy in liquid form. What is the priority parent teaching to be provided by the nurse?
A) The iron should be taken through a straw. B) Positive results from treatment will be seen in 1 to 2 weeks. C) Results will be evaluated through the child's appearance. D) Dosages are determined by serum iron levels.
A 52-year-old male patient has acknowledged to his primary care provider that he has been experiencing difficulty maintaining an erection in recent months
Which of the following assessment questions most directly addresses a risk factor for this problem? A) "How much alcohol do you typically drink in one day?" B) "How much exercise are you getting these days?" C) "Do you have any idea if this is a problem that your father or brothers have had?" D) "Have you been taking a lot of Tylenol or aspirin for pain?"
A nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self-administer the insulin injection. How would this outcome be evaluated?
A) asking the patient to verbally repeat the steps of the injection B) asking the patient to demonstrate self-injection of insulin C) asking family members how much trouble the patient is having with injections D) asking the patient how comfortable he or she is with injections