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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Obtain a throat culture. Throat cultures are contraindicated in suspected epiglottitis because the procedure can provoke airway obstruction and worsen the condition.
B. Visualize the epiglottis using a tongue depressor. Attempting to visualize the epiglottis can lead to sudden airway obstruction in children with epiglottitis. This is dangerous and should be avoided.
C. Initiate airborne precautions. Droplet precautions, not airborne, are necessary for epiglottitis because it is typically caused by bacteria that spread through respiratory droplets.
D. Prepare the child for a neck X-ray and possible tracheostomy. A neck X-ray can help diagnose epiglottitis by showing the characteristic "thumb sign." Immediate airway management, including preparation for a potential tracheostomy, is crucial due to the risk of sudden airway obstruction.
Correct Answer is A
Explanation
A. Rotavirus: The rotavirus vaccine is recommended for infants at 2, 4, and possibly 6 months of age, depending on the vaccine formulation. It helps protect against rotavirus, which can cause severe diarrhea and dehydration in infants.
B. Measles, mumps, rubella (MMR): The MMR vaccine is not given until 12-15 months of age. It is not part of the vaccination schedule for a 4-month-old infant.
C. Varicella (VAR): The varicella vaccine is typically administered at 12-15 months of age. It is not appropriate for a 4-month-old infant.
D. Influenza: The influenza vaccine is recommended annually starting at 6 months of age. A 4-month-old is too young to receive the influenza vaccine.
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