A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?

Increased restlessness

Respiratory rate 25/min

Bowel sounds 20/min

Urinary output 35 mL/hr

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.

Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.

Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.

Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.

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Correct Answer is A

Explanation

Choice A rationale

A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.

Choice B rationale

A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.

Choice C rationale

Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.

Choice D rationale

A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.

A. Increased respiratory rate B. capillary refill of 2 seconds C. Hypertension D. increased urine output .

Correct Answer is A

Explanation

The correct answer is Choice A. An increased respiratory rate is a sign of severe dehydration in infants. Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.

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A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body. Which of the following findings should the nurse report to the provider?

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A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?