QuestionMay 31, 2025

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea.Which of the following findings should the nurse report to the provider? Irritability Flat anterior fontanel Heart rate 160/min Respiratory rate 30/min

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea.Which of the following findings should the nurse report to the provider? Irritability Flat anterior fontanel Heart rate 160/min Respiratory rate 30/min
A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea.Which of the following findings should the nurse
report to the provider?
Irritability
Flat anterior fontanel
Heart rate 160/min
Respiratory rate 30/min

Solution
4.1(258 votes)

Answer

None of the findings require immediate reporting based on typical ranges for a 3-month-old infant. Explanation 1. Identify abnormal findings Compare each finding to typical values for a 3-month-old infant. - **Irritability**: Common in infants with discomfort or illness. - **Flat anterior fontanel**: Normal; bulging or sunken fontanel would be concerning. - **Heart rate 160/min**: Normal range is 100-160/min; upper limit but not abnormal. - **Respiratory rate 30/min**: Normal range is 30-60/min. 2. Determine which finding is concerning None of the findings are outside normal ranges except irritability, which can be common due to illness.

Explanation

1. Identify abnormal findings<br /> Compare each finding to typical values for a 3-month-old infant. <br /><br />- **Irritability**: Common in infants with discomfort or illness.<br />- **Flat anterior fontanel**: Normal; bulging or sunken fontanel would be concerning.<br />- **Heart rate $160/min$**: Normal range is $100-160/min$; upper limit but not abnormal.<br />- **Respiratory rate $30/min$**: Normal range is $30-60/min$.<br /><br />2. Determine which finding is concerning<br /> None of the findings are outside normal ranges except irritability, which can be common due to illness.
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