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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased hematocrit: Hematocrit usually increases in dehydration due to the concentration of red blood cells in a smaller volume of plasma.
B. Increased respiratory rate: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume and maintain oxygen delivery.
C. Decreased heart rate: Dehydration typically causes tachycardia (increased heart rate) as the body tries to maintain adequate blood circulation and pressure.
D. Increased platelet count: Dehydration does not typically affect platelet count significantly, though it may concentrate blood components, including platelets, making them appear elevated on a lab test.
Correct Answer is C
Explanation
A. Wrist: Wrist restraints are typically used to prevent older children or adults from pulling at medical devices or dressings. For an infant, wrist restraints can be too harsh and restrictive. They do not prevent the child from bending their arms, which could allow them to reach their face and potentially disrupt the surgical site.
B. Mummy: A mummy restraint involves wrapping the infant’s body tightly with a blanket to restrict movement, typically used for short periods during medical procedures to keep the child still. This type of restraint is too restrictive for postoperative care and does not allow any movement of the arms, making it uncomfortable and unsuitable for continuous use over extended periods.
C. Elbow: Elbow restraints, also known as no-no’s, are designed to prevent the infant from bending their arms. This type of restraint keeps the elbows straight, preventing the child from touching their face and disrupting the surgical site of the cleft lip and palate. It is effective in allowing the infant to move their arms while ensuring that they cannot interfere with the healing area. This method is less restrictive and more humane for postoperative care in an infant.
D. Jacket: Jacket restraints are used to secure the torso, usually to prevent a child from moving out of bed or a chair. This type of restraint is more restrictive and not specific to preventing arm movement. For an infant recovering from cleft lip and palate surgery, jacket restraints would not effectively prevent the child from reaching their face, and they can be excessively confining and distressing for an infant.
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