Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler?

Question

a. Measuring oral temperature for 5 minutes
b. Counting apical heart rate for 60 seconds
c. Observing chest movement for respiratory rate
d. Recording blood pressure as P/80

Answer 1

B
Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for measuring vital signs in infants and children ages 2 years and younger. A child younger than 6 years may not be able to hold a thermometer under the tongue. The respiratory rate in infants and young children can be measured by watching abdominal movement. It may be difficult to auscultate blood pressure in infants and toddlers. Systolic pressure can be palpated and should be recorded as systolic pressure over pulse (e.g., 80/P).