A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

Heart rate 148/min

Potassium 3.9 mEq/L

Respiratory rate 22/min

Sodium 142 mEq/L

Answer and Explanation

The Correct Answer is A

A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.

B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).

C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.

D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).

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Correct Answer is A

Explanation

A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.

B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.

C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.

D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.

A. "Would you tell me more about the changes you see in your body?" B. "How long have you had these feelings of uselessness? C. "Did anything in particular make you feel this way? D. "Do you ever think about harming yourself?"

Correct Answer is D

Explanation

A. Asking about body changes is important for understanding the client’s self-perception, but it does not address immediate safety concerns.

B. Inquiring about the duration of feelings of uselessness is helpful for assessing depressive symptoms, but it is not the priority over assessing for suicidal intent.

C. Exploring triggers for these feelings is useful for emotional support and planning interventions but is secondary to assessing for immediate risk of self-harm.

D. This question assesses for suicidal ideation, which is the nurse’s priority because older adults experiencing feelings of uselessness or hopelessness are at higher risk for depression and suicide. Early identification of suicidal thoughts ensures prompt intervention and support.

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A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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