A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Weight 14.5 kg (32 lb)

Respiratory rate 45/min

Blood pressure 90/50 mm Hg

Heart rate 110/min

Answer and Explanation

The Correct Answer is B

A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.

B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.

C. A blood pressure of 90/50 mm Hg is normal for a toddler.

D. A heart rate of 110/min is within the expected range for a 3-year-old.

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Correct Answer is A

Explanation

A. A normal urinary output in infants is approximately 1-2 mL/kg/hr. An output of 2 mL/kg/hr would indicate that the fluid imbalance is being corrected.

B. An output of 7.5 mL/kg/hr is excessive and may indicate overhydration or other complications.

C. An output of 0.5 mL/kg/hr is too low and suggests that the fluid imbalance is not yet corrected.

D. An output of 15 mL/kg/hr is too high and could indicate a possible issue such as overhydration.

A. A sibling who had a sore throat 3 weeks ago B. A classmate who has fifth disease C. The father who had gastritis 2 weeks ago D. A neighbor's child who has chickenpox

Correct Answer is A

Explanation

A. Rheumatic fever can develop after a group A streptococcal throat infection (strep throat), typically 2 to 4 weeks after exposure. The sibling with a recent sore throat is likely the source of the infection.

B. Fifth disease is caused by parvovirus B19 and is not linked to the development of rheumatic fever.

C. Gastritis is unrelated to rheumatic fever, which stems from a streptococcal throat infection.

D. Chickenpox is caused by varicella zoster virus and does not lead to rheumatic fever.

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A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

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