A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider?
temperature 37.2 °C (98.9 °F)
pulse 97 beats/min
respiration 52 breaths/min
blood pressure 88/54 mmHg
The Correct Answer is C
A. Temperature of 37.2 °C (98.9 °F) is within normal limits for a child.
B. Pulse of 97 beats/min is normal for a 3-year-old (typical range: 80–120 bpm).
C. Respiration rate of 52 breaths/min is elevated (normal range: 20–30 breaths/min for a 3-year-old) and may indicate respiratory distress or illness, so it should be reported.
D. Blood pressure of 88/54 mmHg is within normal limits for a child of this age.
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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Saying no constantly is not a specific indicator of hearing loss; it may be normal behavior or related to temperament.
B. No speech by two years of age may suggest a hearing impairment affecting language development.
C. Inability to follow age-appropriate directions can indicate the child is not hearing or processing auditory information properly.
D. Frequent scratching at one or both ears may suggest ear infections or discomfort related to hearing issues.
E. Not turning toward loud noises is a classic sign of possible hearing impairment in young children.
Correct Answer is C
Explanation
A. Infants are not developmentally able to interpret language.
B. Toddlers are beginning to use language but do not yet grasp figurative speech.
C. Preschoolers are very literal in their understanding of language and may misinterpret common idioms or metaphors.
D. School-age children begin to understand figurative language.
E. Adolescents typically comprehend abstract and figurative speech well.
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