The nurse is obtaining vital signs for a newborn client. Which route and sequence will the nurse use to obtain vital signs on this client?
1. Rectal temperature, respirations, pulse rate.
2. Respirations, pulse rate, blood pressure, rectal temperature.
3. Respirations, apical pulse rate, axillary temperature.
4. Oral temperature, respirations, pulse rate, blood pressure.
Correct Answer: 3
Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the infant's temperature. While the rectal temperature is the most accurate, there is risk of rectal perforation. This question addresses a "healthy" newborn; therefore an axillary temperature is appropriate. The temperature (any route) should be assessed last, as it may cause the infant to cry, altering the rate of respirations and pulse. A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of two. Oral temperatures are not used for temperature measurement in children under the age of five.
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