A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?

Step 1 is: Calculate the total volume to be infused. 150 mL/hr × 12 hr = 1800 mL Step 2 is: Calculate the total drops per minute. (1800 mL ÷ 720 min) × 20 gtt/mL = 50 gtt/min

The final calculated answer is 50 gtt/min.

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.

Choice E rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice F rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.