Pediatric Vital Signs Exam 2 Question
and Answers with Rationales Latest
Version Top Rated A+
Question 1
A nurse assesses the heart rate of a sleeping 3-year-old child. Which heart rate is considered
normal?
A. 45 bpm
B. 60 bpm
C. 85 bpm
D. 150 bpm
Correct Answer: C. 85 bpm
Rationale:
Preschool children normally have a sleeping heart rate between 60–100 bpm. An 85 bpm heart
rate is expected during sleep.
• A: Too low
• B: Lower end but may be acceptable; 85 is the best answer
• D: Too high while sleeping
Question 2
Which pulse site is preferred when assessing circulation during infant CPR?
A. Radial
B. Carotid
C. Brachial
D. Femoral
Correct Answer: C. Brachial
,Rationale:
For infants younger than 1 year, the brachial pulse is the preferred site during CPR assessment
because it is easy to locate and reliable.
• Radial pulses may be difficult to palpate.
• Carotid assessment is recommended for children older than infancy.
• Femoral may be used but is not the preferred CPR assessment site.
Question 3
A 10-year-old child has a respiratory rate of 32 breaths/minute. What should the nurse conclude?
A. Normal finding
B. Mild bradycardia
C. Tachypnea
D. Respiratory arrest
Correct Answer: C. Tachypnea
Rationale:
Normal respiratory rate for a school-age child is approximately 18–30 breaths/minute. A rate of
32 indicates tachypnea.
Question 4
The nurse measures an infant's axillary temperature as 36.0°C (96.8°F). Which action is
appropriate first?
A. Document as normal
B. Recheck using a reliable method
C. Administer acetaminophen
D. Begin cooling measures
Correct Answer: B. Recheck using a reliable method
Rationale:
Axillary temperatures are less accurate than rectal temperatures in infants. A low reading should
be confirmed before interventions.
Question 5
,Which blood pressure reading is most appropriate for a healthy 7-year-old?
A. 70/40 mmHg
B. 88/54 mmHg
C. 100/65 mmHg
D. 138/90 mmHg
Correct Answer: C. 100/65 mmHg
Rationale:
Normal blood pressure for school-age children is generally around 95–110/60–75 mmHg.
Question 6
A pulse oximeter displays 91% on a healthy child. What should the nurse do first?
A. Ignore the reading
B. Verify probe placement and reassess
C. Call a code
D. Administer epinephrine
Correct Answer: B. Verify probe placement and reassess
Rationale:
Poor probe placement, cold extremities, or movement can cause falsely low readings. Always
verify the reading before escalating care.
Question 7
Which factor most commonly increases a child's heart rate?
A. Deep sleep
B. Fever
C. Hypothermia
D. Athletic conditioning
Correct Answer: B. Fever
Rationale:
Fever increases metabolic demand and commonly raises heart rate by approximately 10–20
beats/minute for each 1°C increase in temperature.
, Question 8
Which child is at greatest risk for inaccurate blood pressure measurement?
A. Child sitting quietly
B. Child using correct cuff size
C. Child with cuff too small
D. Child resting for five minutes
Correct Answer: C. Child with cuff too small
Rationale:
A cuff that is too small falsely elevates blood pressure readings.
Question 9
A newborn has a respiratory rate of 64 breaths/minute immediately after crying. What should the
nurse do?
A. Diagnose respiratory distress
B. Count respirations after the infant is calm
C. Start oxygen immediately
D. Notify the physician
Correct Answer: B. Count respirations after the infant is calm
Rationale:
Crying temporarily increases respiratory rate. Respirations should be measured when the infant
is calm or asleep for the most accurate assessment.
Question 10
Which assessment finding requires immediate intervention?
A. Infant HR 135 bpm while awake
B. Toddler RR 28 breaths/minute
C. School-age SpO₂ 84%
D. Preschool temperature 37.3°C (99.1°F)
Correct Answer: C. School-age SpO₂ 84%
and Answers with Rationales Latest
Version Top Rated A+
Question 1
A nurse assesses the heart rate of a sleeping 3-year-old child. Which heart rate is considered
normal?
A. 45 bpm
B. 60 bpm
C. 85 bpm
D. 150 bpm
Correct Answer: C. 85 bpm
Rationale:
Preschool children normally have a sleeping heart rate between 60–100 bpm. An 85 bpm heart
rate is expected during sleep.
• A: Too low
• B: Lower end but may be acceptable; 85 is the best answer
• D: Too high while sleeping
Question 2
Which pulse site is preferred when assessing circulation during infant CPR?
A. Radial
B. Carotid
C. Brachial
D. Femoral
Correct Answer: C. Brachial
,Rationale:
For infants younger than 1 year, the brachial pulse is the preferred site during CPR assessment
because it is easy to locate and reliable.
• Radial pulses may be difficult to palpate.
• Carotid assessment is recommended for children older than infancy.
• Femoral may be used but is not the preferred CPR assessment site.
Question 3
A 10-year-old child has a respiratory rate of 32 breaths/minute. What should the nurse conclude?
A. Normal finding
B. Mild bradycardia
C. Tachypnea
D. Respiratory arrest
Correct Answer: C. Tachypnea
Rationale:
Normal respiratory rate for a school-age child is approximately 18–30 breaths/minute. A rate of
32 indicates tachypnea.
Question 4
The nurse measures an infant's axillary temperature as 36.0°C (96.8°F). Which action is
appropriate first?
A. Document as normal
B. Recheck using a reliable method
C. Administer acetaminophen
D. Begin cooling measures
Correct Answer: B. Recheck using a reliable method
Rationale:
Axillary temperatures are less accurate than rectal temperatures in infants. A low reading should
be confirmed before interventions.
Question 5
,Which blood pressure reading is most appropriate for a healthy 7-year-old?
A. 70/40 mmHg
B. 88/54 mmHg
C. 100/65 mmHg
D. 138/90 mmHg
Correct Answer: C. 100/65 mmHg
Rationale:
Normal blood pressure for school-age children is generally around 95–110/60–75 mmHg.
Question 6
A pulse oximeter displays 91% on a healthy child. What should the nurse do first?
A. Ignore the reading
B. Verify probe placement and reassess
C. Call a code
D. Administer epinephrine
Correct Answer: B. Verify probe placement and reassess
Rationale:
Poor probe placement, cold extremities, or movement can cause falsely low readings. Always
verify the reading before escalating care.
Question 7
Which factor most commonly increases a child's heart rate?
A. Deep sleep
B. Fever
C. Hypothermia
D. Athletic conditioning
Correct Answer: B. Fever
Rationale:
Fever increases metabolic demand and commonly raises heart rate by approximately 10–20
beats/minute for each 1°C increase in temperature.
, Question 8
Which child is at greatest risk for inaccurate blood pressure measurement?
A. Child sitting quietly
B. Child using correct cuff size
C. Child with cuff too small
D. Child resting for five minutes
Correct Answer: C. Child with cuff too small
Rationale:
A cuff that is too small falsely elevates blood pressure readings.
Question 9
A newborn has a respiratory rate of 64 breaths/minute immediately after crying. What should the
nurse do?
A. Diagnose respiratory distress
B. Count respirations after the infant is calm
C. Start oxygen immediately
D. Notify the physician
Correct Answer: B. Count respirations after the infant is calm
Rationale:
Crying temporarily increases respiratory rate. Respirations should be measured when the infant
is calm or asleep for the most accurate assessment.
Question 10
Which assessment finding requires immediate intervention?
A. Infant HR 135 bpm while awake
B. Toddler RR 28 breaths/minute
C. School-age SpO₂ 84%
D. Preschool temperature 37.3°C (99.1°F)
Correct Answer: C. School-age SpO₂ 84%
