Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler?
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
B
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A A child younger than 6 years may not be able to hold a thermometer under the
tongue.
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.
C The respiratory rate in infants and young children can be measured by watching
abdominal movement.
D 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).
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