A nurse is caring for a 2-month-old infant. Which of the following findings should the nurse report to the provider?
Explanation & Rationale
A. Respiratory rate 18/min: The normal respiratory rate for a 2-month-old infant ranges from 30 to 60 breaths per minute. A rate of 18 is abnormally low and may indicate respiratory depression or impending respiratory failure, requiring immediate medical evaluation. B. Temperature 37.4° C (99.3° F): A normal axillary temperature in infants is 36.5° to 37.5° C (97.7° to 99.5° F). This value is within normal limits and does not suggest fever or hypothermia, so no action is needed. C. Heart rate 160/min: The expected heart rate for a 2-month-old ranges from 100 to 180 beats per minute when awake. A heart rate of 160/min is within normal limits for this age group, particularly during activity or mild stress. D. Blood pressure 95/58 mm Hg: Normal systolic blood pressure for a 2-month-old ranges from 65 to 85 mm Hg, and diastolic from 45 to 55 mm Hg, though some variability exists. A reading of 95/58 mm Hg is slightly elevated but not immediately concerning unless accompanied by other symptoms.