A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?
A.
An adolescent who has a BP of 132/82 mm Hg
B.
A 3-month-old infant who has a respiratory rate of 30/min
C.
An 18-month-old toddler who has a heart rate of 68/min
D.
A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
The Correct answer and Explanation is:
The correct answer is:
C. An 18-month-old toddler who has a heart rate of 68/min
Explanation:
When assessing vital signs, it’s essential to consider normal ranges for different age groups, as these vary significantly between infants, toddlers, and older children. Here’s why the heart rate finding for the 18-month-old toddler is concerning:
- Normal Vital Sign Ranges:
- Adolescent Blood Pressure: For adolescents, a blood pressure of 132/82 mm Hg is on the higher end but can be normal for some individuals. While it may warrant further monitoring, it is not immediately alarming.
- Infant Respiratory Rate: A 3-month-old infant normally has a respiratory rate of 30/min, which falls within the standard range of 30-60 breaths per minute for this age.
- School-Age Child Temperature: A rectal body temperature of 37.3° C (99.1° F) in a school-age child is considered normal. The typical range for rectal temperature in children is between 36.6° C (97.9° F) and 38.0° C (100.4° F), so this reading is within expected limits.
- Normal Heart Rate for Toddlers:
- For an 18-month-old toddler, the normal heart rate ranges from 80 to 130 beats per minute. Therefore, a heart rate of 68/min is significantly below the normal range and is considered bradycardia. Bradycardia in toddlers can be indicative of underlying conditions such as heart disease or issues with the autonomic nervous system. It could also result from the effects of medication or other systemic issues.
- Clinical Importance:
- Bradycardia in toddlers requires immediate assessment to determine the underlying cause. It can lead to reduced cardiac output and impaired oxygen delivery to tissues, which is particularly concerning in young children whose physiological reserves are limited.
In summary, while the other findings are within normal or near-normal ranges for their respective age groups, the bradycardia noted in the 18-month-old toddler is an abnormal finding that requires urgent evaluation by a healthcare provider to address potential serious conditions.