A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?
Heart rate 110/min
Capillary refill greater than 3 seconds
Weight gain of 0.9 kg (2 lb) in a year
Respiratory rate 32/min
The Correct Answer is A
A. Heart rate 110/min: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
B. Capillary refill greater than 3 seconds: Capillary refill time should be less than 2 seconds in a healthy child. A refill time greater than 3 seconds may indicate poor perfusion or dehydration, which is abnormal.
C. Weight gain of 0.9 kg (2 lb) in a year: A weight gain of 2 pounds in a year is below the expected range for a 4-year-old. Children in this age group typically gain around 4-5 pounds per year as they grow.
D. Respiratory rate 32/min: The normal respiratory rate for a 4-year-old child is typically between 20 to 30 breaths per minute. A rate of 32/min is slightly elevated and may indicate respiratory distress or other issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Bring your infant into the clinic today to be seen." This is the appropriate response. Projectile vomiting can be a sign of pyloric stenosis, a condition that requires prompt medical evaluation and potential surgical intervention.
B. "You might want to try switching to a different formula." While switching formula might be considered for minor feeding issues, projectile vomiting is severe and warrants immediate medical attention rather than a dietary change.
C. "Give your infant an oral rehydration solution." Oral rehydration might be useful for dehydration, but it does not address the underlying cause of projectile vomiting, which needs to be diagnosed and treated by a healthcare professional.
D. "Burp your child more frequently during feedings." Although burping can help with mild spit-ups, projectile vomiting is a more serious symptom that requires medical evaluation rather than just a change in feeding practices.
Correct Answer is B
Explanation
A. Hepatitis B (HBV): The Hepatitis B vaccine is typically completed in the infant stage, and a 5-year-old with up-to-date vaccinations would not need a booster for school entry. This is not included in the pre-kindergarten vaccine schedule.
B. Measles, mumps, and rubella (MMR): The MMR vaccine is part of the pre-kindergarten immunization schedule. A second dose is recommended between ages 4 and 6 to ensure immunity before school entry.
C. Haemophilus influenzae type B (Hib): The Hib vaccine is typically administered to infants and young children, and a 5-year-old with up-to-date immunizations would already be fully vaccinated against Hib. No booster is required at this age.
D. Pneumococcal conjugate vaccine (PCV): The PCV vaccine series is usually completed in infancy, and a 5-year-old with current vaccinations would not require a booster. This vaccine is not part of the pre-kindergarten schedule.
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