A nurse is assessing a 24-month-old toddler. Which of the following findings should the nurse report to the provider?
Eats a large amount of food one day then very little the next
Holds his breath when having a temper tantrum
Sleeps 11 to 12 hr per day
Has a vocabulary of 30 words
The Correct Answer is B
A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.
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Related Questions
Correct Answer is A
Explanation
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
Correct Answer is A
Explanation
A. Increased expectoration (coughing up mucus) indicates that the chest physiotherapy treatments have been effective in helping to clear the airways of mucus, which is a common goal in managing cystic fibrosis.
B. Increased urine output is not a direct indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis.
C. Increased heart rate is not a specific indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis. In fact, an increased heart rate may indicate stress or discomfort.
D. Reduced pain is a positive outcome but may not be directly related to the effectiveness of chest physiotherapy in managing cystic fibrosis. The primary goal of chest physiotherapy is to improve airway clearance.
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