A 3-year-old with a congenital heart defect has had a steady decrease in heart rate, now at 76 bpm from 110 bpm four hours ago. Which additional finding should be reported immediately to a healthcare provider?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Blood pressure of 70/40. A significant decrease in heart rate in a 3-year-old with a congenital heart defect is concerning for impending cardiac decompensation. A blood pressure of 70/40 indicates poor perfusion and impending cardiovascular collapse, requiring immediate intervention to stabilize the child's condition. Option A) Oxygen saturation of 94% is within an acceptable range for a 3-year-old and does not indicate an immediate need for intervention. Option B) Respiratory rate of 25 breaths/minute is also within normal limits for a child of this age and does not point towards imminent decompensation. Option C) Urine output of 20 mL/hr is concerning but not as acutely critical as a low blood pressure in this context. Educationally, this question highlights the importance of recognizing subtle changes in vital signs in pediatric patients with congenital heart defects. It emphasizes the need for prompt assessment and intervention to prevent deterioration in a child's condition. Nurses caring for pediatric patients with cardiac conditions must be vigilant in monitoring vital signs and recognizing signs of impending decompensation to provide timely and appropriate care.

Correct Answer: D

Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. A decrease in blood pressure to 70/40 is a critical finding that suggests potential cardiovascular compromise and requires urgent attention to prevent further deterioration.

Correct Answer: D

Rationale: The most important information for the nurse to obtain in this scenario is how often the MDI is used daily. This is crucial to assess if the symptoms the student is experiencing, such as insomnia, shakiness, and tachycardia, could be related to overuse of the inhaler. Overuse of albuterol can lead to side effects like tremors, palpitations, and difficulty sleeping, so understanding the frequency of MDI use is key in determining a potential cause for the student's symptoms.

Correct Answer: B

Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention in this scenario. Anorexia, nausea, and vomiting are common side effects of chemotherapy, which can lead to altered nutrition. Allowing the child to choose foods they desire and can tolerate can help improve their nutritional intake during this challenging time.

Correct Answer: C

Rationale: In pediatric nursing, assessing breath sounds in a crying 18-month-old child requires a strategic approach for accurate evaluation. Option C, allowing the child to play with a stethoscope to distract them during auscultation, is the correct choice. This option promotes a child-friendly environment, reducing anxiety and facilitating a more cooperative assessment. Engaging the child in a non-threatening activity maintains their attention and minimizes resistance, leading to a more accurate evaluation of breath sounds. Option A, documenting unavailability due to crying, is incorrect as it does not address the need for an assessment. Option B, asking the caregiver to quiet the child, may not always be feasible and can lead to increased stress for both the child and caregiver. Option D, auscultating and documenting breath sounds while noting the child was crying, may yield inaccurate results due to the child's distress affecting the breath sounds. Educationally, this rationale highlights the importance of child-centered care in pediatric assessments. It emphasizes the significance of creating a comfortable and engaging environment to ensure accurate evaluations while considering the developmental stage and emotional state of the child. By choosing option C, healthcare professionals can effectively assess breath sounds while promoting a positive experience for the child and caregiver.