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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acute rheumatic fever can cause carditis, which may lead to heart murmurs, tachycardia, or heart failure. Assessing heart sounds is a priority to identify potential complications.
B. Joint pain is an important concern in acute rheumatic fever, but the immediate priority is assessing for signs of carditis or heart complications.
C. An erythematous rash is a characteristic of acute rheumatic fever but is less critical to address immediately compared to potential cardiac involvement.
D. Parental anxiety should be addressed, but the priority is assessing the child’s physical condition, particularly the heart.
Correct Answer is B
Explanation
A. Tetralogy of Fallot involves decreased pulmonary blood flow due to a combination of defects, including pulmonary stenosis.
B. Patent ductus arteriosus (PDA) causes increased pulmonary blood flow due to the abnormal persistence of the ductus arteriosus, leading to a left-to-right shunt and increased blood flow to the lungs.
C. Coarctation of the aorta causes obstructed blood flow, not increased pulmonary blood flow.
D. Tricuspid atresia results in decreased pulmonary blood flow as well due to the lack of a functional tricuspid valve.
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