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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Playing peek-a-boo is ideal for a 7-month-old as it encourages visual tracking, object permanence, and attention, all important for visual development.
B. Playing pat-a-cake involves more advanced motor skills and hand coordination, typically better suited for older infants (around 9 months).
C. Imitating animal sounds is more related to auditory development and language skills, which develop over time.
D. Allowing the child to feel sand focuses on tactile stimulation rather than visual stimulation.
Correct Answer is ["B","D"]
Explanation
A. Asking parents to wait outside may increase toddler anxiety and decrease cooperation.
B. Allowing the child to sit in the parent's lap provides comfort and security, enhancing cooperation.
C. Administering vaccinations before the assessment can cause distress and reduce cooperation.
D. Handing the child a stethoscope engages curiosity and distracts them, which can improve cooperation during assessment.
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