A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child's heart rate is 20 beats/min less than it was preoperatively
a. Follow the orders and check in 2 hours.
b. Ask the parents if this is the child's usual heart rate.
c. Recheck the pulse and blood pressure in 15 minutes.
d. Notify the surgeon that the child is probably going into shock.
ANS: C
In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child's condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child's heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.
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