What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg?
a. Alert the physician about the systolic blood pressure.
b. Comfort the child and assess respiratory rate.
c. Assess the child's responsiveness to the environment.
d. Alert the physician that the child may need intravenous fluids.
A
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A Hypotension is a late sign of shock in children. The lower limit for systolic blood
pressure for a child more than 1 year old is 70 mm Hg plus two times the child's
age in years. A systolic blood pressure of 58 mm Hg calls for immediate action.
The nurse should be direct in relaying the child's condition to the physician.
B This action does not address the problem of shock, which requires immediate
intervention.
C Assessing the child's responsiveness is included in a neurologic assessment. It
does not address the systolic blood pressure of 58 mm Hg.
D Although this child most likely requires intravenous fluids, the physician must be
apprised of the systolic blood pressure so that appropriate intervention can be
initiated.
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