The nurse administers IV morphine to a 4-year-old postoperative client. Which assessment finding requires further evaluation by the nurse?
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
Explanation:
1. The normal pulse rate for children 2 to 5 years of age is between 70 and 120.
2. 90/55 is a normal finding for this age group.
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.
4. This is normal behavior for a 4-year-old child.
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