A nurse is providing care to a 7-year-old male client in the primary care office for a blood pressure check.
Click to highlight the findings that require immediate follow-up.
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- Heart rate: 75/min
- Pulse oximetry: 98% on room air
- Blood pressure: 148/88 mm Hg
- Height: 154.9 cm (61 inches)
- Weight: 44.5 kg (98 lb)
Heart rate: 75/min
Pulse oximetry: 98% on room air
Blood pressure: 148/88 mm Hg
Height: 154.9 cm (61 inches)
Weight: 44.5 kg (98 lb)
The Correct Answer is ["C"]
Choice A rationale: A heart rate of 75/min in a 7-year-old child falls within the normal pediatric range of 70 to 110 beats per minute. Heart rate variability can be influenced by activity, anxiety, or health status. Since this child is alert and cooperative with no signs of distress, this heart rate is physiologically appropriate and does not indicate an urgent cardiovascular problem requiring immediate follow-up.
Choice B rationale: A pulse oximetry reading of 98% on room air is considered within normal limits for a child. Normal oxygen saturation ranges from 95% to 100% in healthy individuals, indicating adequate oxygenation and effective pulmonary gas exchange. Since the child shows no respiratory distress and oxygen saturation is stable, no immediate intervention is necessary based on this value.
Choice C rationale: A blood pressure of 148/88 mm Hg in a 7-year-old is significantly elevated. Pediatric hypertension is defined as systolic or diastolic BP at or above the 95th percentile for age, sex, and height. For this age and height, normal systolic BP is approximately 90–112 mm Hg, and diastolic is 55–75 mm Hg. This reading suggests stage 2 hypertension, requiring urgent evaluation to prevent end-organ damage.
Choice D rationale: Height of 154.9 cm (61 inches) at age 7 is above average but not concerning by itself. Growth charts indicate the 95th percentile for 7-year-old boys is around 128 cm (50 inches). This height is unusually tall, likely indicating early growth spurt or familial tall stature but does not require immediate clinical follow-up unless accompanied by other symptoms.
Choice E rationale: Weight of 44.5 kg (98 lb) at age 7 is significantly above the typical weight range, with the 95th percentile approximately 34 kg. This child is likely obese, which predisposes to hypertension and metabolic complications. However, obesity alone is not an immediate threat requiring urgent follow-up, but it warrants lifestyle counseling and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Detergent pods are highly concentrated and can cause severe chemical burns to the esophagus and respiratory tract if ingested. Their bright colors and soft, squeezable nature can attract young children, making them a significant aspiration and poisoning risk due to their caustic properties. Normal esophageal tissue is delicate and easily damaged by corrosives.
Choice B rationale
Television remote controls, while a common household item, are typically too large and irregularly shaped to be easily aspirated into a toddler's airway. The primary concern with remote controls is choking on small, removable parts like batteries, not aspiration of the entire object into the trachea. Normal airway diameter in toddlers is small.
Choice C rationale
A tennis ball, due to its size and spherical shape, can perfectly occlude a toddler's airway, leading to complete obstruction and potential asphyxiation. Its smooth surface makes it difficult to dislodge once aspirated, posing a significant and immediate life-threatening choking hazard for young children. Normal tracheal lumen can be fully occluded by objects of similar diameter.
Choice D rationale
Hairbrushes are generally too large and awkwardly shaped to be aspirated by a toddler. While bristles or small decorative elements could potentially break off and be ingested, the primary concern with a hairbrush itself is not airway obstruction through aspiration of the entire object. Normal pharyngeal reflexes would typically prevent aspiration of such large objects. .
Correct Answer is ["9"]
Explanation
Step 1 is: Heart rate 120 BPM = 2 points (HR > 100 BPM).
Step 2 is: Strong cry = 2 points (Strong cry/cough).
Step 3 is: Well-flexed = 2 points (Well flexed).
Step 4 is: Reflex-crying = 2 points (Cry/sneeze).
Step 5 is: Body pink; acrocyanosis present in hands and feet = 1 point (Body pink, extremities blue).
Step 6 is: Add up all the points: 2 + 2 + 2 + 2 + 1 = 9.
Answer: 9.
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