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A nurse is caring for the child the following day.

Click to highlight the findings that indicate the child is progressing as expected. To deselect a finding, click on the finding again.

Nurses' Notes

Day 2, 0730:

Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor.

Flow Sheet

Temperature 38.9° C (102° F)

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 104/80 mm Hg

SpO2 98% on room air

A.

Mucous membranes pink and moist

B.

Breath sounds clear anterior posterior bilaterally

C.

Radial pulse 2+ bilateral

D.

Capillary refill less than 2 seconds

E.

Bowel sounds active in all 4 quadrants

F.

Extremities are warm and dry to touch

G.

Good skin turgor

H.

Heart rate 104/min

I.

Respiratory rate 24/min

J.

SpO2 98% on room air

K.

Temperature 38.9° C (102° F)

L.

Drowsy and lethargic

M.

Nuchal rigidity present

N.

Cervical lymph slightly enlarged

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

  • Heart rate 104/min – The heart rate has decreased from 114/min on Day 1, indicating improvement.
  • Respiratory rate 24/min – The respiratory rate has decreased from 26/min, showing stabilization.
  • SpO₂ 98% on room air – Oxygen saturation remains stable and adequate.
  • Mucous membranes pink and moist – Indicates improved hydration.
  • Radial pulse 2+ bilateral – Stronger pulse compared to the previous day’s 1+, suggesting better circulation.
  • Capillary refill less than 2 seconds – Improved from the previous day’s delayed refill (4 seconds), showing better perfusion.
  • Extremities warm and dry to touch – Indicates adequate circulation and hydration.
  • Good skin turgor – Suggests the child is well-hydrated.
  • Bowel sounds active in all 4 quadrants – Indicates normal gastrointestinal function.
  • Breath sounds clear anterior and posterior bilaterally – No respiratory distress or abnormal findings.

Findings that do not indicate improvement:

  • Temperature 38.9°C (102°F) – Slightly higher than the previous day (38.7°C), suggesting persistent fever.
  • Drowsy and lethargic – The child is still lethargic, which may indicate ongoing illness.
  • Nuchal rigidity present – No improvement in meningitis-related symptoms.
  • Cervical lymph slightly enlarged – Indicates ongoing immune response.


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Related Questions

Correct Answer is D

Explanation

A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.

Correct Answer is B

Explanation

A. Heart rate – No data regarding heart rate is provided in the exhibit, so this is not a relevant option.
B. HbA1c – The child's HbA1c level is 8.5%, which is elevated above the normal range (4% to 5.9%). This indicates poor glycemic control, suggesting the development of cystic fibrosis-related diabetes (CFRD), a common complication of cystic fibrosis. This should be reported to the provider for further evaluation and management.
C. WBC count – The WBC count is 9,600/mm³, which is within the normal range (5,000 to 10,000/mm³), so it does not require reporting.
D. Oxygen saturation – No data regarding oxygen saturation is provided in the exhibit, making this option irrelevant.

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