Pediatric Vital Signs II

Pediatrics: Assessment

Key Points ATI Question

Which of the following should
the nurse assess first on a
well-child exam in a 6 week old
1. Talk to parents 1st & then the infant who is sleeping?
child 2nd Auscultation of lung and
heart sounds
2. Always start with least invasive
vitals FIRST TOP Missed NCLEX Question
3. Infants - should be in caregiver’s 10-month old ... crying & vomiting with abdominal
lap during the assessment distension for the past 6 hours. The infant is now
quietly resting with a pulse of 220/min and blood AGE
HEART RATE
HEART RATE

pressure of 85/45. What should the nurse report

Neonate (1-28 days) 110 - 180 bpm
Infant (1-12 months) 110 - 160 bpm
Toddler (1-3) 80 - 110 bpm

FIRST LAST to the HCP?

Client is now lethargic with tachycardia BLOOD PRESSURE
SYSTOLIC
AGE SYSTOLIC DIASTOLIC
HYPOTENSION
Neonate (1-28 days) 60 - 90 20 - 60 <60 (0-28 days old)
Infant (1-12 months) 70 - 105 35 - 55 <70 (1mo - 12mo)
Toddler (1-3) 85 - 105 40 - 65 <70 + (age in year x 2)

The question says:

220 85/45
Tachycardia

Heart & Respiratory Rate

HESI Question
• Count & listen for 1 full minute … assessing the heart rate of a 1 year old?
RESPIRATORY RATE
(60 seconds) for infants and toddlers, Listen to apical pulse for a full minute AGE RESPIRATORY RATE

to screen for irregularities. Neonate (1-28 days)

Infant (1-12 months)
30 - 60 breaths/min
30 - 60 breaths/min

Saunders Question Toddler (1-3)

Preschool Child (3-6)
24 - 40 breaths/min
22 - 34 breaths/min
60
seconds School-age Child (6-12) 18 - 30 breaths/min
12 month old with respiratory infections Adolescent (12-18) 12 - 18 breaths/min

... respiratory rate of 36:

Document the findings

Blood Pressure ATI Question

Blood pressure: 2 year old … 92/60 mm Hg.
… this blood pressure would be:
Normal
• Children have a lower BP than adults due BLOOD PRESSURE
to the smaller size of their organs. AGE SYSTOLIC DIASTOLIC
SYSTOLIC
HYPOTENSION
Neonate (1-28 days) 60 - 90 20 - 60 <60 (0-28 days old)
Infant (1-12 months) 70 - 105 35 - 55 <70 (1mo - 12mo)
Toddler (1-3) 85 - 105 40 - 65 <70 + (age in year x 2)
Preschool Child (3-6) 90 - 110 45 - 70 <70 + (age in year x 2)
School-age Child (6-12) 97 - 120 55 -70 <70 + (age in year x 2)
Adolescent (12-18) 110 - 130 65 - 80 <90

Temperature
Oral temp: 5 - 6 yrs old
Axillary: all ages
Rectal: Infants (most common)
Risk for perforation of the bowel! ATI Question 88%

NOT for immunosuppressed clients & DOXORUBICIN

... child has an oxygen saturation of

those on chemotherapy & radiation
88%.. most appropriate initial action?
NOT for clients with cardiac conditions
88%

Verify the position of the pulse

NOT for clients with diarrhea /
fecal impaction oximetry probe
O2 saturation 38.5

Accurate wave form “steady wave”

matching the child’s pulse