Health Promotion and Maintenance
54. A charge nurse is seated in front of a bank of cardiac monitors on a pediatric unit. There are four children receiving cardiac monitoring. Which finding should the charge nurse communicate at once to the child's nurse?
. A heart rate of 50 in a 15-year-old adolescent who is sleeping.
. A heart rate of 190 in a 1-month-old infant who is crying.
. A heart rate of 160 in a 2-year-old child who is walking in the hallway.
. A heart rate of 75 in a 5-year-old child who is watching television.
Test-Taking Tip
Pay particular attention to the child's activity level when evaluating heart rates. An elevated heart rate during normal or restful activity is more of a concern than a decreased heart rate at rest or an elevated heart rate during vigorous activity.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
.
Answer 1 is incorrect because teenagers have heart rates that generally range from 55 to 90. However, children who are athletic may have even lower heart rates, especially at rest. Answer 2 is incorrect because, although an infant's heart rate ranges from 120 to 160, the rate can near 200 with vigorous crying. If the infant were at rest, a rate of 190 would be suspicious. Answer 3 is correct because the normal heart rate in a 2-year-old child is from 80 to 120 beats per minute. Even though the child is active, this heart rate is quite high and should be investigated further. Answer 4 is incorrect because this is within the range of normal (70 to 100) for a 5-year-old child.