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 restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
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