The nurse obtains the following vital signs on a 1-year-old child—T: 37.8°C rectal; P: 76; R: 24; BP: 92/60. The nurse evaluates vital signs as which of the following?
1. Vital signs are within normal range.
2. The client is hypothermic.
3. The client is hypertensive, and the physician should be notified.
4. The pulse is borderline low, and requires further assessment.
4
Rationale: The client's pulse is borderline low, and further assessment is needed, as this could be normal for the child, or the child could have a problem. Remaining vital signs are within normal limits.
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