Which vital sign change is most concerning in a child with respiratory distress?
Oxygen saturation of 88%.
Heart rate of 160 in a school-age child.
Temperature of 100.4°F.
Respiratory rate of 40 in a toddler.
The Correct Answer is A
Choice A rationale
An oxygen saturation SpO_2 of 88% indicates significant hypoxemia (low blood oxygen), which is the most critical physiological derangement in respiratory distress. Sustained hypoxemia can rapidly lead to cerebral hypoxia, increasing intracranial pressure, and cardiac arrest, necessitating immediate intervention. Normal is ≥ 94-95% in most children.
Choice B rationale
A heart rate of 160 beats per minute in a school-age child (6-12 years) is tachycardia (normal is 75-115 bpm), often an initial compensatory response to hypoxemia and increased work of breathing. While concerning, it is an attempt to maintain cardiac output, making the SpO_2 decline a more immediate life threat.
Choice C rationale
A temperature of 100.4°F is a low-grade fever, which can increase metabolic demand and O_2 consumption, potentially worsening respiratory status. While it warrants management, it is not the most immediate life-threatening sign compared to severe hypoxemia (SpO_2 of 88%). Normal is 97.7°F to 99.5°F.
Choice D rationale
A respiratory rate of 40 breaths per minute in a toddler (1-3 years) is near the upper limit of normal (25-35 bpm) and indicates tachypnea, a compensatory mechanism to improve gas exchange. While significant, it is a sign of compensation, whereas the low SpO_2 suggests decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Stridor is a high-pitched, inspiratory sound resulting from turbulent airflow through a partially obstructed upper airway, specifically the larynx or trachea. In viral croup (laryngotracheobronchitis), inflammation and edema of the subglottic region cause this characteristic narrowing, making stridor a key expected clinical manifestation, especially when the child is agitated or crying.
Choice B rationale
The barking or "seal-like" cough is the hallmark symptom of viral croup, primarily caused by the inflammation and edema localized to the larynx and vocal cords. The narrowed, swollen subglottic area below the vocal cords creates the distinctive resonant sound as air rushes past the restricted space during exhalation, often worsening at night.
Choice C rationale
Hoarseness is a direct result of the inflammatory process affecting the vocal cords within the larynx. The edema and irritation cause the vocal cords to vibrate abnormally, altering the voice's pitch and quality, leading to the rough or husky sound that is commonly observed in children with viral croup.
Choice D rationale
Tripod positioning (sitting upright, leaning forward, with the neck extended) is a compensatory posture typically associated with severe respiratory distress from epiglottitis or a foreign body, indicating imminent airway collapse, but is generally not an expected early finding in the milder upper airway obstruction of viral croup.
Choice E rationale
Drooling results from the inability to swallow secretions due to severe pain and swelling of the epiglottis, making it a cardinal sign of epiglottitis, a bacterial infection. In contrast, viral croup typically involves inflammation lower down in the subglottic area, so drooling is not an expected clinical feature.
Correct Answer is A
Explanation
Choice A rationale
The expected urine output for an infant is 1-2 mL/kg/hr. For this 7.5 kg infant, the minimum expected output is (1 mL/kg/hr× 7.5 kg) × 12 hours = 90 mL. The actual output of 93 mL over 12 hours is just above the minimum of 90 mL, placing it within the normal, expected physiological range.
Choice B rationale
This choice is incorrect because the calculated minimum normal urine output for a 7.5 kg infant over 12 hours is 90 mL. The actual output of 93 mL exceeds this minimum threshold, confirming that the infant's renal excretion is adequate and within the lower bounds of the normal physiological range.
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