A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?
Heart rate 110/min
Capillary refill greater than 3 seconds
Weight gain of 0.9 kg (2 lb) in a year
Respiratory rate 32/min
The Correct Answer is A
A. Heart rate 110/min: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
B. Capillary refill greater than 3 seconds: Capillary refill time should be less than 2 seconds in a healthy child. A refill time greater than 3 seconds may indicate poor perfusion or dehydration, which is abnormal.
C. Weight gain of 0.9 kg (2 lb) in a year: A weight gain of 2 pounds in a year is below the expected range for a 4-year-old. Children in this age group typically gain around 4-5 pounds per year as they grow.
D. Respiratory rate 32/min: The normal respiratory rate for a 4-year-old child is typically between 20 to 30 breaths per minute. A rate of 32/min is slightly elevated and may indicate respiratory distress or other issues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stand above the child's eye level when speaking: The nurse should be at eye level with the child to facilitate lip reading and better communication.
B. Talk directly into the child's impaired ear: This can be uncomfortable and is not effective. The nurse should speak directly to the child, allowing them to use any residual hearing or hearing aids.
C. Speak loudly to the child: Speaking loudly can distort the sounds and make understanding more difficult for hearing-impaired individuals.
D. Speak slowly while facing the child: Speaking slowly and facing the child ensures that they can read lips and facial expressions, which aids in understanding.
Correct Answer is C
Explanation
A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.
B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.
C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.
D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.
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