The nurse administered morphine intravenously to a four-year-old postoperative patient. Thirty minutes later, the nurse assesses the child. Which assessment finding requires further evaluation?
1. Pulse decreased from 136 to 104
2. Blood pressure dropped from 110/72 to 90/55
3. Respiratory rate went from 42 to 16
4. Child pulls away from nurse who wants to assess surgical site
3
Rationale 1: The normal pulse rate for children two to five years of age is between 70 and 120.
Rationale 2: 90/55 is a normal finding for this age group.
Rationale 3: This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child's respirations are being depressed.
Rationale 4: This is normal behavior for a four-year-old child.
Global Rationale:
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