A nurse is caring for the child the following day. Exhibits Click to highlight the findings that indicate the child is progressing as expected. To deselect a finding, click on the finding again. Nurses' Notes Day 2, 0730: Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor. Flow Sheet Temperature 38.9° C (102° F) Heart rate 104/min Respiratory rate 24/min Blood pressure 104/80 mm Hg SpO2 98% on room air
Explanation & Rationale
Rationale for Correct Answers: Mucous membranes pink and moist: Reflects adequate hydration and improved fluid status compared to previous "dry and sticky" description. Respirations are regular/ RR 24/min: Indicates stable respiratory function with no signs of distress or respiratory compromise as compared to the previous irregular respirations HR 104/min / BP 104/80 mm Hg: Demonstrates cardiovascular stability within age-appropriate ranges and an improvement from the initial readings Radial pulse 2+ bilateral / Cap refill < 2 seconds: Suggests good perfusion and improved circulatory status compared to previous delayed cap refill and weak pulses. SpO₂ 98% on room air: Demonstrates sufficient oxygenation without need for respiratory support and an improvement from 97%. Rationale for Incorrect Choices: Drowsy and lethargic, but responsive to verbal stimuli: Neurologic status has not improved from the previous day; continued lethargy and altered mental status require ongoing evaluation. Nuchal rigidity present: This is a classic sign of meningeal irritation and ongoing central nervous system involvement; it has not resolved and remains concerning. Temperature 38.9°C (102°F): The elevated temperature indicates persistent fever, suggesting that the infection or inflammation is still active.