A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Weight 14.5 kg (32 lb)

Respiratory rate 45/min

Blood pressure 90/50 mm Hg

Heart rate 110/min

Answer and Explanation

The Correct Answer is B

A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.

B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.

C. A blood pressure of 90/50 mm Hg is normal for a toddler.

D. A heart rate of 110/min is within the expected range for a 3-year-old.

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Correct Answer is C

Explanation

A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.

B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.

C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.

D. The nurse should address the issue, not refer to the provider for an explanation of their actions.

A. Decrease fluid intake to avoid volume overload. B. Encourage a high protein diet for wound healing. C. Suggest a lower calorie diet due to decreased activity. D. Increase carbohydrate intake for energy.

Correct Answer is B

Explanation

A. Fluid intake should not be decreased; adequate hydration is important for burn patients.

B. A high-protein diet is necessary for wound healing in burn patients as protein is essential for tissue repair and immune function.

C. A lower-calorie diet is not appropriate for burn patients, who often have increased metabolic needs.

D. While carbohydrates are important for energy, protein is the primary focus for wound healing.

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A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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