What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg?

Question

Quizplus · Accepted Answer

Hypotension is a late sign of shock in children.The lower limit for systolic blood pressure for a child more than 1 year old is 70 mm Hg plus two times the child's age in years.A systolic blood pressure of 58 mm Hg calls for immediate action.The nurse should be direct in relaying the child's condition to the physician.Comforting the child and assessing respiratory rate are not priorities.Assessing the child's responsiveness is included in a neurologic assessment.It does not address the systolic blood pressure of 58 mm Hg.Although this child most likely requires intravenous fluids,the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.

What Should Be the Emergency Department Nurse's Next Action When