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Pediatric nursing · practice question

An 8-year-old child in the pediatric unit is being evaluated for well-child care. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which finding requires the nurse to intervene immediately?

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Answer and explanation

Correct answer

D. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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