A nurse is assessing a client who has asthma.
Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Choice A rationale:

Oxygen saturation of 88% on room air is significantly below the normal range (95-100%) and indicates hypoxemia. This finding should be reported to the provider as it may require supplemental oxygen or other interventions.

Choice B rationale:

A heart rate of 128/min is elevated for a school-age child and may indicate increased work of breathing, fever, or other underlying issues. This finding should be reported to the provider for further evaluation.

Choice C rationale:

While the child reporting chest discomfort as 4 on a scale of 0 to 10 is important, it is not as critical as the other findings. The provider should be aware of the discomfort, but it may not require immediate intervention.

Choice D rationale:

An elevated WBC count of 15,000/mm³ indicates an infection, which is consistent with the diagnosis of bilateral pneumonia. While this is important information, it is expected in the context of the current diagnosis and may not require immediate reporting.

Choice E rationale:

Passing three large, frothy, foul-smelling stools is significant in a child with cystic fibrosis as it may indicate malabsorption or other gastrointestinal issues. This finding should be reported to the provider for further evaluation and potential adjustment of the treatment plan.

The correct answer is Choice D.

Choice A rationale

Temper tantrums are not a type of learning disability. They are a normal part of toddler development and are a way for toddlers to express frustration and assert independence.

Choice B rationale

Leaving the room while a tantrum is happening is not recommended. It is important for parents to stay calm and present, providing a safe environment for the child. Ignoring the tantrum while staying nearby can help the child learn to self-regulate.

Choice C rationale

Psychological consults are not typically necessary for temper tantrums. Temper tantrums are a normal part of development and usually decrease as the child learns to communicate and manage emotions better.

Choice D rationale

Temper tantrums are indeed the toddler’s attempt to gain control of a situation. Toddlers often have tantrums when they are unable to express their needs or when they are frustrated by their lack of control over their environment. Understanding this can help parents respond appropriately and support their child’s emotional development.