0510-01
In a 12-month-old infant, the normal respiratory rate is 20 to 40 breaths/minute, the normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg.
0510-02
The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age.
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?
1. Administer oxygen.
2. Document the findings.
3. Notify the health care provider.
4. Reassess the respiratory rate in 15 minutes.
The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?
1. Increase oral fluids.
2. Document the finding.
3. Notify the health care provider (HCP).
4. Elevate the head of the bed to 90 degrees.
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