A nurse is caring for a toddler.
Click to highlight the findings that indicate the toddler requires immediate intervention. To deselect a finding, click on the finding again.
Nurses' Notes
Day 3:
The 2-year-old toddler returns to the provider's office for worsening of symptoms and refusal to eat.
Toddler is listless, laying on guardian's lap. Clear drainage draining from nose. Oral mucosa moist. Audible wheezing noted. Nonproductive, frequent cough present. Moderate subcostal retractions. Apical heart rate regular, no murmur. Abdomen nontender, bowel sounds hyperactive.
Current weight 11.3 kg (25 lb)
Day 3:
Vital Signs
- Temperature 39° C (102.2° F)
- Blood pressure 82/40 mm Hg
- Heart rate 150/min
- Respiratory rate 66/min
- Oxygen saturation 95% on room air
Toddler is listless, laying on guardian's lap
Audible wheezing noted
Moderate subcostal retractions
Apical heart rate regular, no murmur
Temperature 39° C (102.2° F)
Blood pressure 82/40 mm Hg
Heart rate 150/min
Respiratory rate 66/min
Oxygen saturation 95% on room air
The Correct Answer is ["A","B","C","E","F","G","H"]
Rationale for correct choices:
• Listless appearance: A shift from irritability to listlessness signals deteriorating clinical status. In toddlers, decreased responsiveness can reflect significant dehydration or hypoxemia. This neurological change is a red flag requiring urgent intervention.
• Wheezing and Audible Wheezing: Wheezing indicates a narrowing of the airways, which can be caused by inflammation or bronchospasm. While some wheezing was noted on Day 1, the fact that it is now "audible" suggests it is more severe, indicating worsening airway obstruction.
• Respiratory rate of 66/min: A normal respiratory rate for a 2-year-old is 25-30 breaths per minute. A rate of 66/min is tachypnea and is a compensatory to the toddler's inability to get enough oxygen. This high rate in conjunction with retractions indicates severe respiratory distress.
• Moderate subcostal retractions: Retractions are a key sign of respiratory distress. Moderate subcostal retractions indicate a significant increase in the work of breathing and are a red flag for respiratory failure.
• Blood pressure 82/40 mm Hg: This is hypotension for age and suggests poor perfusion from dehydration or sepsis. Hypotension in pediatrics is a late and ominous sign of shock. Rapid fluid resuscitation and close monitoring are priorities.
• Temperature 39° C (102.2° F): High fever significantly increases metabolic demand and oxygen consumption. In a toddler already in respiratory distress, it compounds the risk of hypoxemia and dehydration, requiring prompt antipyretic and supportive management.
Rationale for incorrect choices:
• Oxygen saturation 95% on room air: This oxygen level is within the acceptable range for a toddler, indicating oxygenation is still preserved. The focus should be on addressing worsening work of breathing and circulation, which pose more immediate risks.
• Apical heart rate regular, no murmur: A regular rhythm without a murmur is a normal finding in this context. It provides no evidence of acute hemodynamic instability and thus does not require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rapid respirations: While tachypnea is common in bacterial pneumonia due to increased oxygen demand, it does not directly increase aspiration risk. It reflects respiratory distress rather than impaired protective airway reflexes.
B. Neurological deficit: Children with neurological impairment may have reduced gag and swallow reflexes, poor airway clearance, or altered consciousness. These deficits significantly increase the risk for aspiration, making this the most concerning finding.
C. Elevated temperature: Fever is a systemic response to infection but does not contribute to aspiration risk. It signals the body’s inflammatory process rather than an impairment in airway protection.
D. Inspiratory wheezing: Wheezing indicates narrowed airways due to inflammation or obstruction but does not directly predispose to aspiration. It is a respiratory complication, not a swallowing or airway protection issue.
Correct Answer is B
Explanation
A. Increased appetite: Cefazolin, a cephalosporin antibiotic, does not typically cause an increase in appetite. Instead, gastrointestinal upset such as nausea, vomiting, or diarrhea is more common with this class of drugs.
B. Nausea: Gastrointestinal disturbances, including nausea, vomiting, and diarrhea, are frequent adverse effects of cefazolin. The nurse should monitor for these symptoms as they can affect fluid and nutritional status, especially in children.
C. Hypertension: Cefazolin is not associated with increased blood pressure. Adverse effects more commonly involve gastrointestinal symptoms, hypersensitivity reactions, and, in rare cases, nephrotoxicity or superinfections.
D. Constipation: Constipation is not a typical adverse effect of cefazolin therapy. Instead, diarrhea is more commonly reported due to alterations in normal gastrointestinal flora during antibiotic use.
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