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 A
Explanation
A. "I saw on the internet that there's a new treatment option.": Seeking information and showing interest in possible treatment reflects active coping and problem-focused adjustment. It demonstrates hope, engagement, and willingness to explore ways to support the child.
B. "I don't want my family to know about my child's diagnosis.": Avoiding sharing important information with family members indicates denial and isolation, which can interfere with healthy coping and access to emotional or practical support.
C. "I wish I knew what I did to cause my child to be sick.": This reflects guilt and self-blame, which are common but maladaptive responses. Such thoughts can hinder acceptance and increase emotional distress rather than promoting adjustment.
D. "I am not sure how to care for my dying child.": Expressing uncertainty about caregiving demonstrates anxiety and lack of confidence. While it opens the door for teaching, it does not reflect positive coping or adjustment at this stage.
Correct Answer is C
Explanation
A. Respiratory rate: A respiratory rate of 22/min is within the normal range for a school-age child (18–30/min). This does not suggest acute distress or worsening dehydration, so it does not require reporting.
B. Heart rate: A heart rate of 96/min is normal for a school-age child (75–118/min). It does not indicate tachycardia or hypovolemic compromise and therefore is not concerning.
C. Capillary refill: A prolonged capillary refill time is a key indicator of poor peripheral perfusion, which can be a sign of moderate to severe dehydration and hypovolemia. This finding suggests that the child is not adequately compensating for their fluid loss.
D. Urine output: A urine output of 100 mL in 4 hours is within the expected range for a child of this weight. The normal urine output for a child is approximately 1 mL/kg/hr. For this child (22.7 kg), the expected output would be 22.7 mL/hr. Over 4 hours, this would be 90.8 mL.
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