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A nurse is caring for a 2-year-old male toddler in the emergency department.

Exhibits

Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)

Nasal flaring

Retractions

Oxygen saturation

Breath sounds in bilateral bases

Respiratory rate

Heart rate

Answer and Explanation

Correct Answer : C,D,E

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.

Choice E rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice F rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Ignoring temper tantrums is an effective strategy for managing this behavior. By not giving attention to the tantrum, the child learns that this behavior will not achieve the desired outcome. This approach helps reduce the frequency and intensity of tantrums over time.

Choice B rationale

Restraining the child physically during a temper tantrum can escalate the situation and may cause injury to the child or the caregiver. It is not recommended as a strategy for managing temper tantrums.

Choice C rationale

Distracting the child by offering to play a game can be an effective strategy for preventing tantrums, but it is not the best approach once a tantrum has already started. Ignoring the tantrum is more effective in reducing the behavior over time.

Choice D rationale

Telling the child that temper tantrums are not acceptable may not be effective during the tantrum itself. The child is unlikely to be receptive to verbal reasoning during a tantrum. Ignoring the tantrum is a more effective strategy. .

A. Apex of the heart. B. Brachial artery. C. Radial artery. D. Carotid artery.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants. It is located at the point of maximal impulse (PMI) and provides the most accurate measurement of the heart rate in this age group.

Choice B rationale

The brachial artery is not the preferred site for assessing the heart rate in infants. While it can be used for blood pressure measurement, it is not as accurate as the apical pulse for heart rate assessment.

Choice C rationale

The radial artery is not typically used for assessing the heart rate in infants. It is more commonly used in older children and adults.

Choice D rationale

The carotid artery is not recommended for assessing the heart rate in infants due to the risk of compressing the airway and causing discomfort.

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A nurse is caring for a 2-year-old male toddler in the emergency department. Exhibits Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)

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A nurse is caring for a 2-year-old male toddler in the emergency department.

Exhibits

Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)