A nurse in a provider's office is assessing the vital signs of a 2-year-old child at a well-child visit.
Which of the following findings should the nurse report to the provider?
Blood pressure 118/74 mm Hg.
Respiratory rate 26/min.
Pulse rate 98/min.
Temperature 37.2° C (99° F).
The Correct Answer is A

According to the normal pediatric vital signs chart provided by Cleveland Clinic, the normal blood pressure range for a 2-year-old child should be between 90- 105/55-70 mm Hg. The blood pressure of 118/74 mm Hg is higher than the normal range for a 2- year-old child and should be reported to the provider.
Choice B is wrong because a respiratory rate of 26/min falls within the normal range of 20-30 breaths per minute for a child between ages 1 and.
Choice C is wrong because a pulse rate of 98/min falls within the normal range of 80-125 beats per minute for a child between ages 1 and.
Choice D is wrong because a temperature of 37.2° C (99° F) falls within the normal range for children which is around 98.6 degrees.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy.
This is because the child may be swallowing blood that is coming from the surgical site.
Choice A is wrong because a blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child.
Choice B is wrong because a heart rate of 54/min is within the normal range for a 5-year-old child.
Choice D is wrong because flushing of the face is not an indication of hemorrhage following a tonsillectomy and adenoidectomy.
Correct Answer is C
Explanation
Consistent care from the same nursing staff can help establish a routine and build trust between the infant and caregivers.
Choice A is wrong because giving an infant fruit juice between feedings does not address the underlying causes of failure to thrive.
Choice B is wrong because using half-strength formula when feeding the infant can exacerbate the problem by providing insufficient nutrition.
Choice D is wrong because keeping the infant in a visually stimulating environment does not address the underlying causes of failure to thrive.
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