The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following?

Correct Answer: B

Rationale: The correct answer is B: Record data on nurses’ notes. In this case, the infant's apical pulse of 166 beats/min is within the normal range for a 6-month-old during sleep. By recording this data on the nurses' notes, it ensures accurate documentation for future reference and monitoring. Administering oxygen (choice A) is not indicated as the pulse rate is normal. Reporting the data to the practitioner (choice C) is not necessary since the pulse rate is within the normal range. Placing the child in high Fowler position (choice D) is unrelated to the situation and not indicated based on the information provided.

Correct Answer: C

Rationale: The correct answer is C: Circulatory stasis can lead to thrombus and embolus formation. Immobilization in children can lead to decreased muscle activity and venous return, increasing the risk of blood clots forming in the veins (thrombus) due to stagnant blood flow. These clots can dislodge and travel to the lungs causing a pulmonary embolism. Choices A, B, and D are incorrect because immobilization typically leads to a decrease in metabolic rate, worsens venous return due to lack of movement, and can result in bone demineralization rather than an increase in bone calcium.

Correct Answer: B

Rationale: The correct answer is B because macrophages do indeed derive from monocytes. Monocytes are circulating white blood cells that migrate into tissues and differentiate into macrophages. This process is well-documented in immunology. A: Macrophages are not granulocytes. Granulocytes are a different type of white blood cell characterized by the presence of granules in their cytoplasm. C: Macrophages are highly phagocytic cells, meaning they can engulf and digest foreign particles. Therefore, this statement is incorrect. D: Macrophages primarily reside in the tissues as part of the immune defense system, making this statement incorrect.

Correct Answer: D

Rationale: The correct answer is D, "Antihypertensive." Salicylates are not typically used for lowering blood pressure. Salicylates like aspirin are known for their anti-inflammatory, analgesic, and antipyretic actions. Salicylates inhibit prostaglandin synthesis which helps reduce inflammation, pain, and fever. Other choices are incorrect as salicylates are commonly used for these purposes.

Correct Answer: C

Rationale: The correct answer is C: Sensitivity to cold. Severe anemia can lead to decreased red blood cells, causing poor circulation and reduced oxygen delivery to tissues. This leads to feeling cold due to decreased metabolic activity. Heart palpitations (A) are common but not specific to severe anemia. Fatigue (B) is a common symptom in anemia but not exclusive to severe cases. Exertional dyspnea (D) is due to reduced oxygen-carrying capacity but is not specific to severe anemia.