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?
Respiratory rate 26/min.
Pulse rate 98/min.
Blood pressure 118/74 mm Hg.
Temperature 37.2°C (99° F)
The Correct Answer is C
The correct answer is C. Blood pressure 118/74 mm Hg.
Choice A reason: The respiratory rate of 26 breaths per minute is within the normal range for a 2-year-old child, which is typically 20-30 breaths per minute1. Therefore, this finding does not need to be reported to the provider.
Choice B reason: A pulse rate of 98 beats per minute is also within the normal range for a 2-year-old, which is 90-140 beats per minute. This is a typical finding and does not require reporting to the provider.
Choice C reason: The blood pressure reading of 118/74 mm Hg is higher than the normal range for a 2-year-old, which should be approximately 86-106/42-63 mm Hg. This elevated blood pressure should be reported to the provider as it may indicate an underlying health issue.
Choice D reason: A temperature of 37.2°C (99° F) is at the upper limit of the normal range for body temperature in children and is not typically a cause for concern unless there are other signs of illness1. This temperature does not need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.
Choice B rationale:
Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.
Choice C rationale:
Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.
Choice D rationale:
Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.
Correct Answer is D
Explanation
Choice A rationale:
Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.
Choice B rationale:
Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.
Choice C rationale:
Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.
Choice D rationale:
Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.
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