A nurse is caring for a school-age child in the hospital.
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)
Oxygen saturation: 88% on room air
Heart rate: 128/min
Child reports chest discomfort as 4 on a scale of 0 to 10
WBC: 15,000/mm³
Passed three large, frothy, foul-smelling stools
Correct Answer : A,B,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Reading a story every night is beneficial for cognitive and language development but does not specifically address the developmental task of autonomy versus shame and doubt, which is the focus for toddlers according to Erikson.
Choice B rationale
Allowing a toddler to pull a talking-duck toy fosters autonomy and independence, which are key aspects of Erikson’s developmental stage for toddlers. This activity encourages the child to explore and make choices independently.
Choice C rationale
Feeding the toddler his lunch does not promote autonomy. Instead, it may contribute to dependence, which is contrary to the developmental task of this age group.
Choice D rationale
Watching a puppet show on television is a passive activity that does not actively engage the child in developing autonomy or independence.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
At 10 months, infants are typically able to imitate simple sounds, including animal sounds. This is a normal developmental milestone.
Choice B rationale
Turning pages in a book is a fine motor skill that develops later, around 12 months of age.
Choice C rationale
Building a tower of three or four cubes is a skill that typically develops around 15-18 months of age.
Choice D rationale
By 10 months, infants should be able to sit steadily without support. Inability to do so may indicate a developmental delay.
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