1. To take the vital signs of a 4-month old child, which order will give the most
accurate results?
A. Respiratory rate, heart rate, then rectal temperature
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate:
Answer:
A. Respiratory rate, heart rate, then rectal temperature
The respiratory rate should be taken first in infants, since touching them or
performing unpleasant procedures usually makes them cry, elevating the heart rate
and making respirations difficult to count. Rectal temperature is the most invasive
procedure, and is mot likely to precipitate crying, so should be done last.
2. When planning the care for a child who has had a cleft lip repair, the nurse
knows that crying should be minimized because it
A. increases salivation
B. increases the respiratory rate
C. leads to vomiting
D. stresses the suture line:
Answer:
D. stresses the suture line
Prevention of stress on the lip suture line is essential for optimum healing and the
cosmetic appearance of a cleft lip repair. Although crying also causes increased
salivation, increased respiratory rate and may lead to vomiting, these conditions do
not create a problem for the child with a cleft lip repair.
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