A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

UPUMS Nsg.Officer-2024

Child Health Nursing (Pediatrics)

Hard

Appeared in: UPUMS Nsg.Officer-2024

Explanation

For a 15-year-old adolescent, the normal resting heart rate is 60-100 beats per minute (bpm). A rate of 105 bpm is considered tachycardia (abnormally fast heart rate).
The normal respiratory rate for this age group is 12-20 breaths per minute. A rate of 22 breaths/min is considered tachypnea (abnormally rapid breathing).
The normal blood pressure is approximately 110-131 mmHg systolic and 64-83 mmHg diastolic. A reading of 105/60 mmHg is considered low (hypotension).
Since the heart rate, respiratory rate, and blood pressure are all outside the established normal ranges for an adolescent, this set of vital signs is abnormal.

Option A: The vital signs for the 6-year-old female (HR 100, RR 26, BP 90/70) are within or very close to the normal limits for a school-age child (HR: 75-118 bpm, RR: 18-25 breaths/min, BP: 97-120/57-80 mmHg). While the BP is slightly low, it's not as clearly abnormal as the values in option D.
Option B: The vital signs for the 5-year-old male (HR 102, RR 24, BP 90/65) are within the normal limits for a preschooler (HR: 80-120 bpm, RR: 20-29 breaths/min, BP: 89-112/46-72 mmHg).
Option C: The vital signs for the 11-year-old male (HR 90, RR 22, BP 100/70) are within the normal limits for a school-age child (HR: 75-118 bpm, RR: 18-25 breaths/min, BP: 97-120/57-80 mmHg).

Clinical Relevance

Nursing practice connection: Knowing Normal Pediatric Vital Signs helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate assessment and interpretation of pediatric vital signs are fundamental nursing skills. Deviations can be the earliest indicators of serious conditions like sepsis, shock, respiratory distress, or cardiac problems.
It is critical to use age-specific charts for vital signs, as a value that is normal for one age group can be a sign of critical illness in another.
What if? If the 15-year-old female also reported feeling dizzy and appeared pale, the nurse's priority would be to immediately place her in a supine position, notify the primary healthcare provider, and prepare for potential interventions for hypovolemic or septic shock.

How to Approach the Question

Identify the core task: The question asks you to find the one set of vital signs that is abnormal.
Analyze each option individually. For each option, note the patient's age.
Recall the normal vital sign ranges (Heart Rate, Respiratory Rate, Blood Pressure) for that specific age group (preschooler, school-age, adolescent).
Systematically compare the given values in the option to the established normal ranges.
The option where one or more vital signs fall clearly outside the normal range is the correct answer. Pay special attention to options where multiple values are abnormal.

Concept Tested & Keywords

Concept Tested: Normal Pediatric Vital Signs
Stem keywords: vital signs, abnormal, 6 years old, 5 years old, 11 years old, 15 years old
Lead-in keywords: Which
Negative lead-in flag: false