Pediatric Vital Signs Exam 3 Question
and Answers with Rationales Latest
Version Top Rated A+
Question 1
A nurse is assessing a healthy 6-month-old infant. Which heart rate is within the expected resting
range?
A. 60 beats/min
B. 85 beats/min
C. 130 beats/min
D. 180 beats/min
Correct Answer: C. 130 beats/min
Rationale:
A normal resting heart rate for a 6-month-old infant is approximately 100–160 beats/min. A rate
of 130 beats/min is expected. A rate of 60 or 85 is too low for this age, while 180 beats/min is
generally above the expected resting range.
Question 2
Which pediatric patient is most likely to have the highest normal respiratory rate?
A. 15-year-old adolescent
B. 10-year-old child
C. 2-year-old toddler
D. Newborn infant
Correct Answer: D. Newborn infant
Rationale:
Normal respiratory rates decrease with age. Newborns typically breathe 30–60 breaths/min,
making them the age group with the highest normal respiratory rate.
,Question 3
When measuring an infant's apical pulse, the nurse should auscultate for at least:
A. 15 seconds
B. 30 seconds
C. 45 seconds
D. 60 seconds
Correct Answer: D. 60 seconds
Rationale:
Infants commonly have irregular heart rhythms. Counting the apical pulse for a full minute
provides the most accurate assessment.
Question 4
Which blood pressure reading is most concerning in a 5-year-old child?
A. 98/60 mmHg
B. 104/68 mmHg
C. 76/44 mmHg
D. 102/64 mmHg
Correct Answer: C. 76/44 mmHg
Rationale:
This blood pressure is lower than expected for most healthy preschool-aged children and may
indicate hypotension, particularly if accompanied by signs of poor perfusion.
Question 5
The nurse is assessing respirations in a sleeping infant. Which technique provides the most
accurate count?
A. Count chest movements for 15 seconds × 4.
B. Observe abdominal movement for one full minute.
C. Wake the infant before counting.
D. Count while the infant is crying.
Correct Answer: B. Observe abdominal movement for one full minute.
,Rationale:
Infants are diaphragmatic breathers, so abdominal movement best reflects respirations. Counting
for a full minute is recommended because infant breathing patterns may be irregular.
Question 6
A temperature of 38.4°C (101.1°F) in a 2-year-old is classified as:
A. Hypothermia
B. Normal temperature
C. Fever
D. Hyperpyrexia
Correct Answer: C. Fever
Rationale:
A temperature of 38.0°C (100.4°F) or higher is generally considered a fever in children.
Question 7
Which vital sign should the nurse reassess first after a frightened toddler has been crying
vigorously?
A. Respiratory rate
B. Weight
C. Height
D. Head circumference
Correct Answer: A. Respiratory rate
Rationale:
Crying temporarily elevates heart rate and respiratory rate. These should be reassessed after the
child has calmed.
Question 8
A school-age child has a resting respiratory rate of 22 breaths/min. How should the nurse
interpret this finding?
, A. Below normal
B. Within expected range
C. Dangerously elevated
D. Indicates respiratory failure
Correct Answer: B. Within expected range
Rationale:
Normal respiratory rates for school-age children are approximately 18–30 breaths/min, making
22 breaths/min appropriate.
Question 9
Capillary refill longer than 3 seconds may indicate:
A. Adequate circulation
B. Poor peripheral perfusion
C. Normal hydration
D. Hypertension
Correct Answer: B. Poor peripheral perfusion
Rationale:
Delayed capillary refill can indicate decreased tissue perfusion and warrants further assessment.
Question 10
Which oxygen saturation requires immediate nursing assessment in an otherwise healthy child?
A. 99%
B. 98%
C. 96%
D. 89%
Correct Answer: D. 89%
Rationale:
An oxygen saturation below 90% generally indicates significant hypoxemia requiring prompt
evaluation.
and Answers with Rationales Latest
Version Top Rated A+
Question 1
A nurse is assessing a healthy 6-month-old infant. Which heart rate is within the expected resting
range?
A. 60 beats/min
B. 85 beats/min
C. 130 beats/min
D. 180 beats/min
Correct Answer: C. 130 beats/min
Rationale:
A normal resting heart rate for a 6-month-old infant is approximately 100–160 beats/min. A rate
of 130 beats/min is expected. A rate of 60 or 85 is too low for this age, while 180 beats/min is
generally above the expected resting range.
Question 2
Which pediatric patient is most likely to have the highest normal respiratory rate?
A. 15-year-old adolescent
B. 10-year-old child
C. 2-year-old toddler
D. Newborn infant
Correct Answer: D. Newborn infant
Rationale:
Normal respiratory rates decrease with age. Newborns typically breathe 30–60 breaths/min,
making them the age group with the highest normal respiratory rate.
,Question 3
When measuring an infant's apical pulse, the nurse should auscultate for at least:
A. 15 seconds
B. 30 seconds
C. 45 seconds
D. 60 seconds
Correct Answer: D. 60 seconds
Rationale:
Infants commonly have irregular heart rhythms. Counting the apical pulse for a full minute
provides the most accurate assessment.
Question 4
Which blood pressure reading is most concerning in a 5-year-old child?
A. 98/60 mmHg
B. 104/68 mmHg
C. 76/44 mmHg
D. 102/64 mmHg
Correct Answer: C. 76/44 mmHg
Rationale:
This blood pressure is lower than expected for most healthy preschool-aged children and may
indicate hypotension, particularly if accompanied by signs of poor perfusion.
Question 5
The nurse is assessing respirations in a sleeping infant. Which technique provides the most
accurate count?
A. Count chest movements for 15 seconds × 4.
B. Observe abdominal movement for one full minute.
C. Wake the infant before counting.
D. Count while the infant is crying.
Correct Answer: B. Observe abdominal movement for one full minute.
,Rationale:
Infants are diaphragmatic breathers, so abdominal movement best reflects respirations. Counting
for a full minute is recommended because infant breathing patterns may be irregular.
Question 6
A temperature of 38.4°C (101.1°F) in a 2-year-old is classified as:
A. Hypothermia
B. Normal temperature
C. Fever
D. Hyperpyrexia
Correct Answer: C. Fever
Rationale:
A temperature of 38.0°C (100.4°F) or higher is generally considered a fever in children.
Question 7
Which vital sign should the nurse reassess first after a frightened toddler has been crying
vigorously?
A. Respiratory rate
B. Weight
C. Height
D. Head circumference
Correct Answer: A. Respiratory rate
Rationale:
Crying temporarily elevates heart rate and respiratory rate. These should be reassessed after the
child has calmed.
Question 8
A school-age child has a resting respiratory rate of 22 breaths/min. How should the nurse
interpret this finding?
, A. Below normal
B. Within expected range
C. Dangerously elevated
D. Indicates respiratory failure
Correct Answer: B. Within expected range
Rationale:
Normal respiratory rates for school-age children are approximately 18–30 breaths/min, making
22 breaths/min appropriate.
Question 9
Capillary refill longer than 3 seconds may indicate:
A. Adequate circulation
B. Poor peripheral perfusion
C. Normal hydration
D. Hypertension
Correct Answer: B. Poor peripheral perfusion
Rationale:
Delayed capillary refill can indicate decreased tissue perfusion and warrants further assessment.
Question 10
Which oxygen saturation requires immediate nursing assessment in an otherwise healthy child?
A. 99%
B. 98%
C. 96%
D. 89%
Correct Answer: D. 89%
Rationale:
An oxygen saturation below 90% generally indicates significant hypoxemia requiring prompt
evaluation.
