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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The pneumococcal conjugate vaccine (PCV13) is recommended for children with sickle cell anemia. This is because individuals with sickle cell disease are at an increased risk of infection, and the PCV13 vaccine can help protect against Streptococcus pneumoniae, a bacterium that can cause serious infections like pneumonia and meningitis.
Choice B rationale
The Respiratory syncytial virus (RSV) vaccine is not typically included in the immunization schedule for children with sickle cell anemia.
Choice C rationale
While the Measles, Mumps, and Rubella (MMR) vaccine is part of the standard immunization schedule for all children, it is not specifically indicated for children with sickle cell anemia.
Choice D rationale
The Rotavirus vaccine is part of the standard immunization schedule for all infants, but it is not specifically indicated for children with sickle cell anemia.
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.
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