A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?
A.
Respiratory rate 68/min.
B.
BP 64/42 mm Hg.
C.
Axillary temperature 36.6° C (97.9° F).
D.
Apical heart rate 124/min.
The correct answer and Explanation is :
The correct answer is A. Respiratory rate 68/min.
Explanation:
In pediatric care, it is essential to know the normal ranges for vital signs, as they vary with age. For a 2-week-old infant, the expected reference ranges are as follows:
- Respiratory rate: A normal respiratory rate for a newborn (birth to 1 month) typically falls between 30 to 60 breaths per minute. A respiratory rate of 68 breaths per minute is above this range, indicating tachypnea (fast breathing), which can be a sign of respiratory distress, infection, or other medical conditions. Therefore, the respiratory rate of 68/min is outside the expected range.
- Blood pressure: For a newborn, the normal blood pressure can vary but generally falls around 60-80/40-50 mm Hg. In this case, the infant’s blood pressure is 64/42 mm Hg, which is within the normal range for a 2-week-old infant.
- Temperature: The normal axillary (armpit) temperature for an infant is around 36.5-37.5°C (97.7-99.5°F). The temperature provided is 36.6°C (97.9°F), which is well within the normal range for a 2-week-old infant.
- Apical heart rate: The expected apical heart rate (pulse) for a newborn is typically between 100-160 beats per minute. The heart rate of 124/min is within the normal range for a 2-week-old infant.
Why is tachypnea concerning?
An increased respiratory rate, or tachypnea, in a newborn could be a response to various issues, including infection, respiratory distress, or metabolic problems. It is crucial to monitor the infant closely for signs of distress such as grunting, nasal flaring, or cyanosis. If tachypnea persists, further evaluation may be necessary, including checking for infections, cardiovascular issues, or lung problems.
In summary, while the blood pressure, heart rate, and temperature are within normal limits, the respiratory rate of 68/min is outside the expected reference range, indicating a need for further assessment.