Suggested Answers for Discussion Topics, Chapter 26, Vital Sign Assessment
Suggested Answers for Topics for Discussion / Learning Objective(s)1. Students’ answers may include:
· The interventions used by the nurse when assessing the client’s pulse rate include the following:
o Assess the radial artery. This is the most commonly assessed site in the clinical setting and is palpated on the thumb side of the inner aspect of the wrist.
o Palpate the pulse using the first and second or second and third fingers of one hand. Light pressure should be used initially to locate the area of the strongest pulsation. Forceful palpation may be applied to count the rate, determine the rhythm, and assess the quality of the pulse.
o Count the number of pulses for 30 or 60 seconds and multiply appropriately. This yields pulses per minute. Intervals of 15 seconds may be used for the client with regular rhythms when reassessing the pulse frequently, as during recovery from anesthesia. Count the initial pulsation as zero, regardless of the time interval selected, to avoid overestimating the pulse rate. / 5
2a. Students’ answers may include:
· The nurse should provide the following instructions to the client:
o Temperature, pulse, and respirations fluctuate widely in newborns because their thermoregulatory mechanisms are immature, and ambient temperature may affect the newborn’s body temperature markedly.
o Healthy newborns may exhibit periodic apnea. Pulse and respiration increase rapidly above resting values when a newborn is active, crying, or startled.
2b. Students’ answers may include:
· The interventions followed by the nurse for accurate measurement and interpretation of the infant’s vital signs include the following:
o Use the apical pulse as an appropriate method of assessing heart rate because peripheral pulses are faint, difficult to palpate, and difficult to count accurately in the infant.
o Safety considerations become important when monitoring the vital signs of the infant. Babies may move quickly, so protecting them from falling or injury during vital sign monitoring is essential.
o Tympanic or axillary temperature monitoring is preferred for the infant, because rectal temperature monitoring can cause mucosal tearing or perforation, and an infant would not safely hold an oral thermometer in the mouth. / 7
3. Students’ answers may include:
· Interventions followed by the nurse to ensure the client’s safety include:
o Check the client’s postural vital signs as one way of screening for the risk of falls.
o Instruct the client to move from a lying to a sitting or a standing posture by allowing several minutes to elapse before proceeding to the next position.
o Measure orthostatic blood pressure in the client exhibiting symptoms of fainting and dizziness.
o Use a systematic, consistent technique when assessing the client’s blood pressure and heart rate response to position change to acquire best data for determining and monitoring therapy. / 5