The nurse is caring for a pediatric client and needs to obtain vital signs. Which of the following route and sequence will the nurse use to obtain vital signs on a healthy newborn?
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
3
Rationale 1: The temperature should be taken last, as it may cause the infant to cry, altering the rate of respirations and pulse.
Rationale 2: 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 2.
Rationale 3: Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the temperature. The rectal temperature is the most accurate; however an axillary temperature is appropriate since it can lead to rectal perforation.
Rationale 4: Oral temperatures are not used for temperature measurement in children under the age of 5.
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