Editing Pediatric Nursing – RN Practice Questions (section)

==Question 2==
The nurse assesses a 4-year-old with a 2-day history of vomiting and diarrhea. Which findings indicate '''compensated shock''' and require immediate intervention? '''Select all that apply.'''
# Heart rate 168 beats per minute
# Capillary refill of 4 seconds
# Blood pressure 92/58 mmHg
# Cool, mottled extremities with weak peripheral pulses but strong central pulses
# Increasing lethargy and decreased response to the parent's voice
# Urine output of 0.3 mL/kg/hr

'''Answer:''' 1, 2, 4, 5, and 6.

''Rationale:'' Children compensate for volume loss with tachycardia and peripheral vasoconstriction. Tachycardia, delayed capillary refill beyond 2 to 3 seconds, cool mottled skin with a central-to-peripheral pulse discrepancy, declining level of consciousness, and oliguria (expected output for a child is 1 to 2 mL/kg/hr) all indicate compensated shock. Option 3 is not a sign of shock: the hypotension threshold for a 4-year-old is a systolic pressure below 70 + (2 x 4), or 78 mmHg, so 92 mmHg is within normal limits. That is exactly the trap. Hypotension is a late and ominous sign, and the nurse must intervene on the compensated findings rather than waiting for the blood pressure to fall.