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 C
Explanation
A. Oxygen saturation: An oxygen saturation of 95% is within the normal range for a school-age child and acceptable for a client with cystic fibrosis, who may have mild baseline respiratory compromise.
B. WBC count: A WBC count of 9,600/mm³ is within the normal pediatric range (5,000–10,000/mm³). It does not suggest acute infection or bone marrow suppression, so it is not a reportable finding.
C. HbA1c: An HbA1c of 8.5% is significantly elevated above the normal range (4%–5.9%). This indicates poor glycemic control, suggesting cystic fibrosis–related diabetes, a common complication. This requires provider notification for further evaluation and management.
D. Heart rate: A heart rate of 98/min is within the normal range for school-age children (75–118/min). It does not indicate acute distress or cardiac complications, so it does not warrant immediate reporting.
Correct Answer is B
Explanation
A. "Wear a feminine deodorant pad for vaginal drainage.": Deodorant pads contain chemicals and fragrances that can irritate the vaginal area and worsen vulvovaginitis. Instead, unscented cotton pads or liners are preferred if drainage management is needed.
B. "Apply a warm, moist compress three times per day.": Warm, moist compresses help relieve discomfort, reduce inflammation, and promote healing. This is an appropriate supportive measure for managing symptoms of vulvovaginitis.
C. "Wear nylon underwear at night.": Nylon underwear traps heat and moisture, creating an environment conducive to irritation and infection. Breathable cotton underwear is recommended to promote dryness and comfort.
D. "Apply scented baby powder to absorb residual moisture.": Scented powders can irritate the sensitive vulvar tissue and are not recommended. Good hygiene and breathable fabrics are safer ways to control moisture.
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