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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 A

Explanation

A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.

B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.

C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.

D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.

Correct Answer is A

Explanation

A. "Lifts head 45° when lying prone." By 2 months of age, infants begin lifting their heads about 45 degrees while on their stomachs, which is an early sign of developing neck and upper body strength.
B. "Rolls over from back to abdomen." Rolling from back to abdomen typically occurs around 6 months of age.
C. "No head lag when pulled into a sitting position." Head lag is still present at 2 months, but it gradually disappears by 4 months as neck muscles strengthen.
D. "Rolls over from abdomen to back." Rolling from abdomen to back typically occurs around 4 months of age, followed by rolling from back to abdomen at about 6 months.

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